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Total endovascular aortic arch repair (TEAAR) represents an emerging alternative for the treatment of aortic arch disease in patients at prohibitive risk for open surgery. A systematic review of TEAAR was performed to delineate early outcomes with this new technology.All studies (excluding single-patient case reports) of CE-certified "custom made" or "off-the-shelf" zone 0 stent graft deployments were included. The primary search of Medline, Embase, CINAHL, and the Cochrane CENTRAL registry was supplemented with searches of Web of Science, ClinicalTrials.gov, and conference abstracts (within last 3 years), and a hand search of citations within relevant articles. Articles underwent 2-stage screening by 2 independent reviewers before inclusion.Fifteen relevant investigations were identified. Indications for TEAAR were chronic arch dissection with degenerative aneurysmal disease (54%, 148/273), pure arch aneurysm (41%, 112/273), penetrating atherosclerotic ulcer (2%, 5/273), and type IA endoleak from a zone 2 thoracic endograft (1%, 3/273). Double-branch (70%, 192/273), triple-branch (19%, 53/273), and single-branch (into innominate artery; 10%, 28/273) devices were used. Adjunct left carotid-subclavian bypass occurred in 90% of double- and single-branch procedures. Procedural success with TEAAR was 93% (95% CI 85.8%-96.3%). The proportion of all-cause mortality was 16% (95% CI 8%-26%), stroke 14% (8%-24%), peripheral vascular events 7% (1%-33%), and myocardial infarction 4% (2%-7%). Endoleaks were identified in 13% (7%-25%) of the study population.TEAAR represents an emerging option for the management of aortic arch disease wth high procedural success rates and acceptable early outcomes in a high-risk patient population.

After repair of acute type A aortic dissection, typical geometric variables of conventional aortic surveillance focus on maximum diameter and its rate of growth, potentially missing important geometric changes elsewhere. We determined additional information provided by a semiautomated, 3-dimensional (3D), nonlinear growth model of the descending thoracic aorta after repair of type A aortic dissection.Computed tomographic angiography data were retrospectively collected after hemiarch repair of type A aortic dissection. The descending aorta was systematically reconstructed to generate a 3D model made up of individual segments. The baseline and follow-up diameters were measured semiautomatically for each segment, and the nonlinear interval growth was determined.The fastest growing segment expanded at a rate of 3.8 mm/y (interquartile range, 2.2 to 5.4 mm/y) vs 0.6 mm/y (interquartile range, -0.3 to 1.7 mm/y) when measured at the original site of maximum diameter (P.01). The maximum baseline diameter was a poor predictor of location with fastest growth (r = 0.10, P.1). Using the society recommended growth limits, a greater proportion of patients would be considered "at risk" when assessed by our method vs conventional surveillance measures.Our model identifies areas of rapid aortic growth after repair of type A dissection that would likely be missed using current surveillance techniques. The increased precision, resolution, and reproducibility provided by our technique may improve on limitations of current surveillance techniques, provide novel geometric data on aortic remodeling, and contribute to the pursuit of a comprehensive patient-specific approach to aortic risk stratification.

Endovascular therapies have had a considerable impact on contemporary management of thoracic aortic disease. Still, with the anatomic challenges of the aortic arch, endovascular experience with devices that traverse the arch and deploy in the Zone 0 position remains limited. We report the first Canadian experience with the RelayBranch Thoracic Stent Graft (Terumo Aortic, Sunrise, FL) with Zone 0 deployment for total endovascular aortic arch repair in a patient at very high risk for redo open surgery. We demonstrate safe deployment of the device and successful treatment of a type 1A endoleak. Features of the RelayBranch design that mitigate challenges of arch deployment are also discussed. Résumé: Les traitements endovasculaires ont eu un impact considérable sur la gestion contemporaine des pathologies de l'aorte thoracique. Pourtant, en raison des contraintes anatomiques de la crosse aortique, l'expérience endovasculaire avec des dispositifs qui traversent la crosse et se déploient dans la zone 0 reste limitée. Nous rapportons la première expérience canadienne de l'endoprothèse thoracique RelayBranch avec déploiement (Terumo Aortic, Sunrise, FL) en zone 0 pour une réparation endovasculaire totale de la crosse aortique chez un patient présentant un risque très élevé de reprise de chirurgie ouverte. Nous décrivons le déploiement en toute sécurité du dispositif et le traitement réussi d'une endofuite de type 1A. Enfin, nous examinons les caractéristiques du système RelayBranch qui limitent les difficultés liées au déploiement du dispositif dans la crosse aortique.

OBJECTIVES: Extended-arch techniques offer the potential to comprehensively treat acute type-A aortic dissection (ATAAD), but add surgical complexity compared to the standard hemiarch technique. This study describes both perioperative and mid-term outcomes following the introduction of an extended-arch technique for ATAAD. METHODS: Ours is a retrospective single-centre observational study of 95 consecutive patients with ATAAD from 2011 to 2016. The decision to perform extended-arch or hemiarch repair was individualized based on clinical and radiological features. Extended-arch repair was defined as replacement of the ascending aorta and arch with reimplantation of head vessels with or without distal endovascular extension. Clinical follow-up was 100% complete. Cross-sectional double-oblique measurements were performed for aortic remodelling analysis. RESULTS: Extended-arch (n = 28) and hemiarch (n = 67) repair resulted in a in-hospital mortality of 10% (n = 3) and 10%, (n = 7), and permanent neurological deficit rate of 7% and 12%, respectively. At a mean imaging follow-up duration of 2.7 ± 1.5 years, false lumen thrombosis was achieved in 57% and 9% of patients undergoing extended-arch and hemiarch repair, respectively. Rate of growth in the proximal descending aorta was 0.7 ± 2.3 mm/year in the extended-arch group vs 2.7 ± 3.9 mm/year in the hemiarch group. At a mean clinical follow-up time of 3.0 ± 1.6 years, open surgical aortic reoperation was 0% in the extended-arch group and 22% in the hemiarch group. CONCLUSIONS: Extended-arch repair of ATAAD can be introduced in the acute setting without increase in perioperative mortality or morbidity. At mid-term follow-up, extended-arch for ATAAD improves aortic remodelling and reduces the need for open surgical reoperation.

Background Acute pulmonary embolism (PE) has a wide spectrum of outcomes, but the best method to risk-stratify normotensive patients for adverse outcomes remains unclear. Methods A multicentre retrospective cohort study of acute PE patients admitted from emergency departments in Calgary, Canada, between 2012 and 2017 was used to develop a refined acute PE risk score. The composite primary outcome of in-hospital PE-related death or haemodynamic decompensation. The model was internally validated using bootstrapping and the prognostic value of the derived risk score was compared to the Bova score. Results Of 2067 patients with normotensive acute PE, the primary outcome (haemodynamic decompensation or PE-related death) occurred in 32 (1.5%) patients. In simplified Pulmonary Embolism Severity Index high-risk patients (n=1498, 78%), a multivariable model used to predict the primary outcome retained computed tomography (CT) right–left ventricular diameter ratio ≥1.5, systolic blood pressure 90–100 mmHg, central pulmonary artery clot and heart rate ≥100 beats·min−1 with a C-statistic of 0.89 (95% CI 0.82–0.93). Three risk groups were derived using a weighted score (score, prevalence, primary outcome event rate): group 1 (0–3, 73.8%, 0.34%), group 2 (4–6, 17.6%, 5.8%), group 3 (7–9, 8.7%, 12.8%) with a C-statistic 0.85 (95% CI 0.78–0.91). In comparison the prevalence (primary outcome) by Bova risk stages (n=1179) were stage I 49.8% (0.2%); stage II 31.9% (2.7%); and stage III 18.4% (7.8%) with a C-statistic 0.80 (95% CI 0.74–0.86). Conclusions A simple four-variable risk score using clinical data immediately available after CT diagnosis of acute PE predicts in-hospital adverse outcomes. External validation of the Calgary Acute Pulmonary Embolism score is required., Derivation of a simple four-variable risk score that uses parameters available at the time of PE diagnosis to risk stratify acute normotensive PE patients, which may help clinicians better decide how to monitor and treat patients https://bit.ly/37PdyrM

BACKGROUND The Perceval Valve (LivaNova, London, United Kingdom) is a rapid-deployment aortic bioprosthesis with a stentless self-expanding design conducive to minimally-invasive approaches. Uptake of this valve may be limited by sizing-related nuances and its unique implantation technique. Three-dimensional modeling and printing of custom patient-specific models can be used for surgical teaching and preoperative planning. Herein, we describe our method for 3D-printing aortic roots using a semi-flexible material and demonstrate their utility for sizing and surgical planning before Perceval Valve Implantation. METHODS AND RESULTS Semiflexible models of aortic roots were virtually modelled and 3D-printed from DICOM files containing contrast-enhanced ECG-gated CTA images of the thoracic aorta obtained in patients awaiting surgical aortic valve replacement via right anterior minithoracotomy. Segmentation of the aortic root, annulus and the left ventricular outflow tract was performed using a free, open source, multi-platform software package ( http://slicer.org ). In Slicer, a three-dimensional shell was generated around the luminogram model and then hollowed out, replicating the interior of the aortic root. After converting the aortic surfaces to standard tessellation language (STL), the models were printed using Thermoplastic Polyurethane (NinjaFlex, NinjaTek, PA,USA) in a direct drive extruder desktop 3D printer (Printrbot Simple Metal, Printrbot, USA). Preliminary model validation was performed in a prospective and blinded manner. Surgeons sized two de-identified aortic roots prior to the patient's operation. Implantation was then performed in the operating room without knowledge of the model sizing. The same size selected in the model corresponded to the size implanted in the operating room. The root models correctly predicted the size of the implanted valve. They also demonstrated the consequences of incorrect sizing (Image). Undersizing resulted in poor leaflet coaptation. Oversizing resulted in pinwheeling or buckling of the Perceval valve, both oversizing-related complications. A prototype holder was developed for simulation of the implantation procedure, including guiding suture placement, traction-countertraction of the sutures and balloon expansion. CONCLUSION Custom 3D-printed semiflexible aortic roots allowed for simulation of intraoperative sizing and can reproduce surgically relevant signs of inappropriate sizing, including oversizing (pinwheeling and buckling) and undersizing (suboptimal coaptation). This model will be of use for preoperative planning, sizing and surgical proctoring for the Perceval valve. Custom modeling may accelerate the learning curve associated with this valve and improve uptake for use in minimally invasive aortic valve surgery, combined cases, and patients with small roots.

Advances in open and endovascular techniques have resulted in novel approaches to repair of acute Type A aortic dissection. Hybrid arch procedures involve open arch resection and stent grafting of the descending aorta with stent graft insertion in one of two ways: Frozen or Staged. In this article, pros and cons of the two different paradigms of emerging hybrid arch techniques for acute Type A aortic dissections are discussed.

Conventional surgical techniques for acute Type A aortic dissection (ATAAD) generally fail to address residual dissection in the descending aorta. The persistence of a false lumen is associated with visceral malperfusion in the acute setting and adverse aortic remodeling in the chronic setting. Hybrid aortic arch repair techniques may improve perioperative and long-term mortality by expanding the true lumen and obliterating the false lumen. However, there is a limit to the extent of aortic coverage due to the concomitant risk of spinal cord ischemia. In Type B dissection, the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique, which entails stent graft coverage of the primary intimal tear followed by bare metal stent placement distally, may improve true lumen caliber and promote false lumen thrombosis without increasing the risk of spinal cord ischemia, as intercostal branches remain perfused through the bare metal stents. The technique of hybrid arch with surgical creation of a Dacron landing zone covering a stent graft in the proximal descending aorta and bare metal stents in the thoraco-abdominal aorta is a promising concept in the treatment of ATAAD.

Introduction: Normotensive acute pulmonary embolism (aPE) has a wide spectrum of outcomes. The best method to identify patients at higher-risk remains unclear. Aims and Objectives: 1) develop a unique prognostic model for adverse outcomes in normotensive aPE, 2) validate the Bova score in a North American population. Methods: This was a multi-centre retrospective cohort of all aPE admitted from emergency departments in Calgary, Canada between 2012-2017. Logistic regression models with bootstrapping for internal validation were used to predict the composite primary outcome of in-hospital death or hemodynamic decompensation. Results: 2067 patients with normotensive aPE were assessed. A primary outcome occurred in 32 patients (1.5%). Stratified by simplified pulmonary embolism severity index (sPESI), 21.2% were low-risk (0% event rate) and 78.8% were high-risk (2.0% event rate). The multivariable model in sPESI high-risk patients (n=1179) retained high-sensitivity troponin ≥50 pg/ml, CT right-left ventricular diameter ratio ≥1.5, systolic blood pressure Conclusions: Our novel risk score discriminated normotensive aPE patients at high risk of in-hospital adverse events better than the Bova score. Further validation of our score is warranted.

Objective: 5 year retrospective study of patients presenting to emergency departments at the four tertiary care hospitals in Calgary, Alberta with upper extremity (UE) deep vein thrombosis (DVT) to define the patient population, determine practice patterns and management of upper extremity clots. Methods: All adult patients with suspected upper extremity DVT presenting to any of the four tertiary care centers in the Calgary health region and who had undergone diagnostic imaging were included in the study. Ultrasounds and CT scans were obtained from the Diagnostic Imaging department from January 2014 to December 2018. Inclusion criteria included patients above 18 years of age and evidence of deep, superficial or catheter-associated upper extremity venous thrombosis on imaging. Exclusion criteria were any known cancer or life expectancy under 6 months. Basic demographic data were collected, in addition to disposition from emergency, choice of anticoagulant, duration of anticoagulation, history of thrombophilia and thoracic outlet obstruction (TOO) work-up. Results: 1236 patient records were reviewed, of which 151 (12.2%) were positive for UE deep venous thrombosis (DVT) and 114 (9.2%) for superficial vein thrombosis (SVT). Mean age was 47 years and 50.2% were males. Duration of treatment for both DVT and SVT ranged anywhere from no therapy to lifelong treatment, with an average of 5.01 months for DVT and 1.15 months for SVT. 22.5% of all DVTs were recommended lifelong therapy. 21 (18.4%) patients were treated for more than 45 days for SVT, of which only 9 had another indication for anticoagulation. Common risk factors identified for DVT included line associated thrombosis (17.2%), of which 38.5% were specifically PICC associated, trauma (2.6%) and intravenous drug use (2.0%). Anticoagulant agents for DVT included low molecular weight heparin (7.9%), direct oral anticoagulants (DOACs) (39.1%) and warfarin (42.4%). 8.6% of the DVTs received no treatment. Follow-up was variable from the emergency department ranging from following up with the patient's own family physician to sending an urgent referral to General Internal Medicine, Hematology or Vascular surgery. 30.5% of the patients with DVT were referred to General Internal Medicine (GIM) outpatient, compared to 24.5% to Hematology and 33.7% to their family doctor. 29.8% of the patients with SVT were referred to GIM, 7.9% to Hematology and 66.7% to their family doctor. 39.7% of the people with DVT were tested for thrombophilia, of which 10% tested positive for any type of thrombophilia. 29.8% were tested for TOO, of which 48.9% were found to have TOO and 11.1% received surgery for same. Conclusion: Our study demonstrates that there is significant variability in the management of upper extremity clots, highlighting the lack of literature in this field. Developing a structured, standardized approach along with ongoing provider education could help reduce this variability and optimize management of this patient population. Disclosures No relevant conflicts of interest to declare.

Objective To review the early results of a less invasive, single-stage hybrid arch procedure involving replacement of the ascending aorta, arch debranching, and zone 0 antegrade stent graft deployment. Methods Between May 2007 and January 2012, 20 patients with both acute and chronic aortic pathology were managed at 2 institutions with a type 2 hybrid arch procedure. Indications included diffuse atherosclerotic aneurysm, false lumen expansion of chronic aortic dissections, penetrating atherosclerotic ulcer, and acute type A dissection. Mean age was 67 ± 16.8 years with a mean European System for Cardiac Operative Risk Evaluation II score of 29.5 ± 19.4. Postoperative clinical and imaging follow-up was complete to a mean 18.5 ± 15.3 months. Results Successful zone 0 stent graft deployment was achieved in all cases. There was 1 in-hospital mortality (5%). A second death occurred at 40 days postoperation. Other complications included a permanent neurologic deficit in 1 patient (5%), transient paraplegia in 4 patients (20%), and 3 patients had respiratory complications (15%). There were no cases of renal failure requiring dialysis. Stent-related complications were identified in 4 patients (20%), including 3 type I endoleaks, none of which were at zone 0. There was 1 type II endoleak and a case of stent infolding. Two patients required a second successful endografting procedure. Conclusions This single-stage hybrid arch procedure offers an alternative approach to complex diffuse aortic pathology involving the arch. Replacement of the ascending aorta provides a safe location for zone 0 stent graft deployment, eliminating complications of proximal deployment in a native diseased aorta.

Potential benefits of extending the distal extent of repair for acute type A aortic dissection beyond hemiarch has prompted the exploration of various total arch repair approaches. A zone 2 arch is advocated by some surgeons but the nomenclature and technique have not been described.

A 59-year-old man presented with recurrent upper gastrointestinal bleeding (UGIB) following an initial episode of gallstone pancreatitis in 2003. He underwent cholecystectomy but then had multiple hospital admissions for recurrent pancreatitis complicated by a large inflammatory pancreatic head mass in 2009. A Whipple’s procedure was attempted, but extensive adhesions to multiple vascular structures prevented safe resection of the pancreatic head mass and the procedure was converted to a roux-en-Y procedure. Ongoing inflammation and fibrosis surrounding the portal vein led to noncirrhotic portal hypertension complicated by large varices. These were first recognized in November 2011 when the patient presented with UGIB, treated with endoscopic variceal injection with N-butyl-2-cyanoacrylate (NBCA) (Histoacryl, Tuttlingen, Germany). The patient had multiple hospitalizations (8 admissions over a 22-month period) including an intensive care unit admission for lifethreatening UGIB secondary to both gastric and duodenal varices. These were managed medically with multiple blood transfusions (over 10 U in total), octreotide, and pantoprazole. Endoscopy was performed at each admission and therapy consisting of NBCA injections and variceal banding was performed when active UGIB was identified. Additionally, a suspicion of sinistral portal hypertension was treated with splenic debulking using staged partial particle embolization of the spleen followed by main splenic artery embolization. This was complicated by splenic abscess requiring splenectomy and distal pancreatectomy in 2012. In April 2013, further surgical management with a side-to-side portocaval shunt at the level of the porta hepatis was performed. No varices were ligated at the time of surgery. Despite these multiple treatments, the patient had two further episodes of UGIB requiring hospitalization. CT examination in June 2013 demonstrated a 2.8-cm long occlusion of the main portal vein at the level of the pancreatic head mass in addition to large gastric and duodenal varices (Fig. 1). Endovascular recanalization of the portal vein occlusion was now considered his best treatment option. Under conscious sedation with fentanyl (Sandoz, QC, Canada) and midazolam (Pharmaceutical Partners of & Mollie C. M. Ferris Mollie.Ferris@albertahealthservices.ca

Background The ascending aorta, with its hostile angulations and forces, is the next frontier in the evolution of endovascular surgery. Type II hybrid arch repair, involving surgical replacement of the ascending aorta, arch debranching, and stent graft deployment in the ascending aortic graft, offers an opportunity to study the behavior of an endovascular prosthesis in the ascending aorta. We report complications seen at the proximal landing zone after type II hybrid arch repair. Methods A dedicated imaging protocol was used to monitor 20 consecutive patients who underwent type II hybrid arch repair at a single center from June 2009 to July 2014. Results Mean age was 66 years (range, 47 to 82 years). Mean imaging follow-up was 34 months (range, 12 to 64 months). There was 1 operative death (5%). Bird beaking (>5 mm of nonapposition) of the stent graft at the proximal landing zone occurred in 12 patients, and >20 mm of bird beaking occurred in 7 patients. Proximal landing zone complications occurred in 4 patients (20%), comprising 2 type Ia endoleaks, 1 graft migration, and 1 graft infolding detected on postoperative days 4, 11, 5, and 755, respectively. Three patients underwent endovascular reintervention for proximal landing zone complications. There were no late deaths. Conclusions Thoracic aortic stent grafts may be prone to proximal landing zone complications when deployed in the ascending aorta. Bird beaking is common when endografts are deployed in the Dacron (DuPont, Wilmington, DE) ascending aorta. Angulation issues will likely need to be overcome by stent graft refinement to enable future closed chest approaches to the ascending aorta.

Importance The natural history of ascending aortic aneurysm (AsAA) is currently not well characterized. Objective To summarize and analyze existing literature on the natural history of AsAA. Data Sources A search of Ovid MEDLINE (January 1, 1946, to May 31, 2017) and Embase (January 1, 1974, to May 31, 2017) was conducted. Study Selection Studies including patients with AsAA were considered for inclusion; studies were excluded if they considered AsAA, arch, and descending thoracic aneurysm as 1 entity or only included descending aneurysms, patients with heritable or genetic-related aneurysms, patients with replaced bicuspid aortic valves, patients with acute aortic syndrome, or those with mean age less than 16 years. Two independent reviewers identified 20 studies from 7198 unique studies screened. Data Extraction and Synthesis Data extraction was performed according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline; 2 reviewers independently extracted the relevant data. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance–weighted random-effects model. Metaregression was performed to assess the relationship between initial aneurysm size, etiology, and the primary outcomes. Main Outcomes and Measures The primary composite outcome was incidence of all-cause mortality, aortic dissection, and aortic rupture. Secondary outcomes were growth rate, incidence of proximal aortic dissection or rupture, elective ascending aortic repair, and all-cause mortality. Results Twenty studies consisting of 8800 patients (mean [SD] age, 57.75 [9.47] years; 6653 [75.6%] male) with a total follow-up time of 31 823 patient-years were included. The mean AsAA size at enrollment was 42.6 mm (range, 35.5-56.0 mm). The combined effect estimate of annual aneurysm growth rate was 0.61 mm/y (95% CI, 0.23-0.99 mm/y). The pooled incidence of elective aortic surgery was 13.82% (95% CI, 6.45%-21.41%) over a median (interquartile range) follow-up of 4.2 (2.9-15.0) years. The linearized mortality rate was 1.99% per patient-year (95% CI, 0.83%-3.15% per patient-year), and the linearized rate of the composite outcome of all-cause mortality, aortic dissection, and aortic rupture was 2.16% per patient-year (95% CI, 0.79%-3.55% per patient year). There was no significant relationship between year of study completion and the initial aneurysm size and primary outcomes. Conclusions and Relevance The growth rate of AsAA is slow and has implications for the interval of imaging follow-up. The data on the risk of dissection, rupture, and death of ascending aortic aneurysm are limited. A randomized clinical trial may be required to understand the benefit of surgical intervention compared with surveillance for patients with moderately dilated ascending aorta.

Complications may arise from the residual dissected arch and descending thoracic aorta after conventional ascending and hemiarch repair of acute DeBakey type I aortic dissection. To mitigate these complications, a total arch and elephant trunk procedure has been advocated. This case demonstrates a less invasive hybrid technique, performed in a single-stage fashion through a sternotomy without circulatory arrest or deep hypothermia, to achieve the benefits of the total arch and elephant trunk operation.

Diffuse thoracic aortomegaly has conventionally been managed with a two-stage elephant trunk procedure, requiring prolonged circulatory arrest, with an inherent risk of major morbidity and mortality. Recently, to improve outcomes, several hybrid arch procedures have been proposed using off-pump techniques. We have adopted an alternative, single-stage hybrid strategy using cardiopulmonary bypass without circulatory arrest to replace the ascending aorta and perform arch debranching and antegrade endovascular stent graft deployment. Unlike off-pump procedures, pathology of the aortic valve, root, and ascending aorta is addressed while avoiding the complications of stent graft placement in the native ascending aorta.

We describe a case of complete endovascular repair of the ascending aorta using a transfemoral approach. A 59-year-old man with a history of two previous sternotomies experienced an ascending aortic pseudoaneurysm arising from the graft-to-graft anastomosis of a previous DeBakey type I aortic dissection repair. A custom-made Zenith TX2 (William Cook Europe ApS, Bjaeverskov, Denmark) thoracic aortic aneurysm endovascular graft, designed specifically for the ascending aorta, was introduced through the left femoral artery and deployed under a rapid ventricular pacing protocol to achieve precise placement between the sinotubular junction and the aortic arch.

Background Endovascular options to repair the arch and ascending aorta are rapidly evolving. Little is known about the durability of endovascular devices deployed at this location. This report describes a single-centre experience with the novel application of thoracic endovascular aortic repair (TEVAR) by examining clinical and radiological outcomes. Methods A retrospective review was performed for a cohort of patients undergoing TEVAR of the arch or ascending aorta, or both, at a single centre from November 2008-July 2012. Results Sixteen patients were included in the study, with mean imaging follow-up of 38 months (range, 15-72 months). Two complications at the proximal landing zone in the ascending aorta were identified: 1 endoleak and 1 infolding identified at 3 and 24 months postoperatively, respectively. Clinically, both these complications were attributed to the bird-beak configuration at the proximal landing zone site. At up to 72 months of follow-up, there were no cases of retrograde dissection of the native sinus of Valsalva. There were no cases of stent graft migration, graft fracture, open surgical reintervention for aortic pathologic conditions, or late mortality. Conclusions Early outcomes suggest that the current generation of thoracic aortic endografts can be placed in the complex anatomy of the ascending aorta and aortic arch without a high incidence of early graft fracture or migration. Future endeavors will need to focus on techniques to achieve optimal apposition with the curves of the ascending aorta. These findings are important as indications for endovascular aortic therapies expand to address proximal aortic pathologic conditions.

The authors have seen four cases of asymptomatic delayed intimal injury adjacent to a stent graft diagnosed 7 to 16 months after thoracic endovascular aortic repair. Endovascular repeat intervention was successfully performed in three of the four cases as described in the present report. A second consecutive “intimal blowout” in one patient remains under close radiologic surveillance. Possible causes for the intimal blowouts, including stent-graft size, landing zone anatomy, and intrinsically weak aortic tissue, are discussed.

Objectives Distal extent of repair in patients undergoing surgery for acute Type A aortic dissection (ATAAD) is controversial. Emerging hybrid techniques involving open and endovascular surgery have been reported in small numbers by select individual centres. A systematic review and meta-analysis was performed to investigate the outcomes following extended arch repair for ATAAD. A classification system is proposed of the different techniques to facilitate discussion and further investigation. Methods Using Ovid MEDLINE, 38 studies were identified reporting outcomes for 2140 patients. Studies were categorized into four groups on the basis of extent of surgical aortic resection and the method of descending thoracic aortic stent graft deployment; during circulatory arrest (frozen stented elephant trunk) or with normothermic perfusion and use of fluoroscopy (warm stent graft): (I) surgical total arch replacement, (II) total arch and frozen stented elephant trunk, (III) hemiarch and frozen stented elephant trunk and (IV) total arch and warm stent graft. Perioperative event rates were obtained for each of the four groups and the entire cohort using pooled summary estimates. Linearized rates of late mortality and reoperation were calculated. Results Overall pooled hospital mortality for extended arch techniques was 8.6% (95% CI 7.2-10.0). Pooled data categorized by surgical technique resulted in hospital mortality of 11.9% for total arch, 8.6% total arch and frozen stented elephant trunk, 6.3% hemiarch and frozen stented elephant trunk and 5.5% total arch and 'warm stent graft'. Overall incidence of stroke for the entire cohort was 5.7% (95% CI 3.6-8.2). Rate of spinal cord ischaemia was 2.0% (95% CI 1.2-3.0). Pooled linearized rate of late mortality was 1.66%/pt-yr (95% CI 1.34-2.07) with linearized rate of re-operation of 1.62%/pt-yr (95% CI 1.24-2.05). Conclusions Perioperative results of extended arch procedures are encouraging. Further follow-up is required to see if long-term complications are reduced with these emerging techniques. The proposed classification system will facilitate future comparison of short- and long-term results of different techniques of extended arch repair for ATAAD.

PINAL CORD ISCHEMIA is a potentially devastating complication following any repair of the descending thoracic aorta. The literature suggests that the risk with descending aortic surgery may be lower with endovascular compared with open intervention. 1,2 Current estimates for the incidence of spinal cord ischemia with endovascular repair is in the range of 3% to 7%. 1-3 Thoracic aortic aneurysmal disease involving the aortic arch conventionally has required open repair involving cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. Despite technical advances in surgical technique and perioperative care, the risk of mortality or significant morbidity remains high. 4,5 Hybrid arch repair is an evolving surgical approach for diffuse aortomegaly. It involves 2 steps, which can be performed together during a single surgery or staged over time. The first step involves conventional open aortic branch revascularization, while thoracic endovascular aortic repair (TEVAR) completes the process. Various approaches to the hybrid arch repair exist, with a wide range of reported incidence of neurologic complications. 6-8 Several risk factors have been identified for spinal cord ischemia in patients undergoing TEVAR, including previous abdominal aortic repair, hypotension, coverage of the left subclavian artery, and extensive endograft coverage. 9-16 The authors present a case of left subclavian graft thrombosis as a possible new etiology for delayed paraplegia in a patient following hybrid arch repair.