Abstract:Indirect innominate artery (IA) cannulation provides important advantages of central arterial inflow and antegrade cerebral perfusion in proximal aortic surgery but is often avoided when the artery is dissected. We describe a stepwise technique enabling indirect cannulation of a dissected IA through circumferential false lumen exclusion and adventitia-true lumen reapproximation. In nine patients with dissected IA undergoing this approach, cannulation was successfully achieved without in-hospital mortality or permanent neurological deficit.
Abstract:Patient factors can present formidable challenges in emergent aortic surgery. We report successful mechanical aortic root, ascending aorta, and Zone 2 arch replacement under hypothermic circulatory arrest in a 305 kg patient with acute type A aortic dissection. A dual-oxygenator bypass circuit, proactive metabolic management, bilateral fasciotomies, and early renal replacement therapy were critical to a favorable outcome.
Abstract:Porcelain aortic arch with coronary artery disease poses a major surgical challenge. We report a 66-year-old man with a large arch pseudoaneurysm, circumferential arch calcification, left common carotid artery thrombosis, and triple-vessel coronary disease who underwent single-stage total arch replacement with coronary artery bypass grafting. Surgery utilized axillary and femoral cannulation, hypothermic circulatory arrest, and selective antegrade cerebral perfusion. Complete recovery followed a transient postoperative neurological deficit, demonstrating feasibility of tailored open repair.
Abstract:Optimal management of the aortic arch during repair of acute type A aortic dissection remains debated. Hemiarch repair can achieve acceptable early survival, but persistent false lumen perfusion and residual distal dissection may contribute to later distal aortic enlargement or reintervention in a subset of patients. The frozen elephant trunk (FET) technique aims to improve distal aortic remodeling by covering intimal tears, expanding the true lumen, and promoting false lumen thrombosis, but it adds operative complexity because it requires more extensive arch reconstruction and supra-aortic vessel management. The Ascyrus Medical Dissection Stent (AMDS), an uncovered nitinol stent, has emerged as an adjunct to hemiarch repair. It is intended to reduce distal anastomotic new entry tears, support true lumen expansion, and facilitate distal aortic stabilization without formal total arch replacement. Contemporary evidence from the DARTS and PERSEVERE studies and observational series suggests that FET and AMDS may serve different operative goals in selected patients, although their roles are overlapping rather than mutually exclusive. FET may be more suitable when more extensive distal arch or proximal descending aortic pathology is present, whereas AMDS may be considered when a less extensive arch procedure is desired in the setting of arch instability or malperfusion. Neither approach should be viewed as universally superior. Instead, strategy should be individualized on the basis of patient age, intimal tear location, malperfusion status, operative risk, and institutional experience. AMDS may represent an additional option in selected high-risk patients.
Background:Ascending aortic and aortic root pseudoaneurysms are rare but potentially life-threatening complications, most commonly occurring after prior cardiac or aortic interventions. Management remains challenging and may require complex surgery or, in selected cases, endovascular therapy. We reported the experience of a single cardiovascular center in the management of aortic pseudoaneurysms. Methods:We retrospectively reviewed 12 consecutive patients treated for thoracic aortic pseudoaneurysms between August 2008 and November 2025. Demographic, perioperative, and follow-up data were obtained from the institutional Society of Thoracic Surgeons (STS) database. Descriptive statistics were used for baseline characteristics and outcomes. Overall survival was estimated using Kaplan-Meier analysis. Results:Mean patient age was 56 ± 14 years, and 83.3% were male. All patients had prior cardiac interventions. Five patients (41.6%) had infected pseudoaneurysms. Median pseudoaneurysm size was 6.55 cm. Ten patients underwent open surgical repair, and two underwent percutaneous treatment. Hospital mortality was 8.3%. Postoperative stroke occurred in 16.7%, acute kidney injury in 16.7%, and atrial fibrillation in 25%. Median follow-up was 28 months with overall mortality of 16.7%. Estimated survival at the end of follow-up was 85%. One late death occurred in a patient with candidemia and recurrent infection. Conclusion:Surgical repair of ascending aortic pseudoaneurysms can be performed with acceptable morbidity and mortality and is effective in most patients. Infected pseudoaneurysms remain particularly challenging. In carefully selected high-risk patients, endovascular approaches provide a feasible less-invasive alternative with reasonable mid-term outcomes.
Introduction:Acute aortic dissection remains a hazardous and unpredictable condition. Although it is the most common acute aortic disease requiring surgical intervention, still up to 35% of patients are misdiagnosed on the initial presentation. Presentation of aortic dissection is protean, contributing to confusion in diagnosis and a delay in appropriate, timely intervention. Early and accurate diagnosis and treatment are crucial for survival. The clinical diagnosis of aortic dissection depends on awareness of the entity, keen clinical suspicion, and an understanding of its varied manifestations. Unfortunately, many patients die before they can receive hospital treatment. Materials and Methods:A total number of 208 patients diagnosed with Type A aortic dissection (TAAD) and operated on in our center from June 2014 to June 2019 were included in the study. After review of the medical records of 178 patients, data were available for 162 patients. The aim was to delineate presentation patterns, various clinical manifestations, and radiological features of Stanford TAAD. Univariate analysis was used to provide frequency distribution and percentage distribution of qualitative demographic and comorbidity variables. Mean ± standard deviation was reported, whereas for non-normally distributed quantitative variables, median ± (min-max) was reported. Data analysis was performed using the Statistical Package for Social Sciences, version 18.0 (SPSS, Chicago, IL). Results:A total of 162 patient records were reviewed; 131 (80.8%) patients were male, and 31 (19.2%) were female. The mean age of all patients was 43.3 years (± 13.49). A total of 146 patients (90.1%) had TAAD, and 16 patients (9.8%) had chronic TAAD. Severe pain was the most common presenting symptom, and 88.9% of patients reported chest pain. Four patients (2.7%) had renal malperfusion, and 23 (14%) had lower limb ischemia, with three having bilateral lower limb ischemia. Five patients had cerebrovascular accidents of new onset on presentation. Chest radiography showed mediastinal widening in 143 patients (88.8%). Two-dimensional (2D) echocardiography patients (87%) had dilated ascending aortas, with dissection flaps seen in 131 (81.4%) patients. Computed tomography (CT) dimensions-aortic valve annulus mean diameter was 31.5 mm (± 7.1), with the maximum diameter being 50 mm and minimum diameter being 16 mm. Conclusion:The clinical characteristics and radiological features of TAAD in the past 10 years in our center were analyzed. We also compared our data with those reported by International Registry for Aortic Dissection, Japan Registry of Aortic Dissection, and German Registry for Acute Aortic Dissection Type A. Acute chest pain was the most common presenting complaint. CT angiography was the investigation of choice, with TTE being a helpful supportive tool. The majority of our patients had TAAD despite aortic diameter being less than 55 mm. Our demographic data and clinical presentation were similar to Chinese data, owing to similar socio-economic backgrounds.
Background:Degree of malperfusion on presentation is a known determinant of early mortality in acute Type A aortic dissection (TAAD). Its prediction of mortality when stratified by complexity of central repair has not been well-described. Methods:Over a 6-year period, 183 patients had a central repair for TAAD, 146 of whom had a spontaneous etiology and an acute presentation (≤14 days). Each patient was assigned a Penn Class based on ischemia (malperfusion): A-none, B-regional, or C-global. The index operation was identified as simple (ascending aorta and/or hemiarch replacement) or complex (concomitant root replacement, arch replacement, or coronary artery bypass grafting). Early mortality was defined as in-hospital or within 30 days of surgery, if discharged. Results:The overall early mortality was 10.3% (15/146), and it was significantly different in each Penn Class: 1.5% (1/65) for A, 8.7% (4/46) for B, 22.8% (8/35) for C (p = 0.002). Six patients in Penn Class C had preincision cardiac arrest with cardiopulmonary resuscitation, three surviving. The early mortality differences, however, between the simple (8.3%) and complex (14.0%) operative groups overall and within each Penn Class were not significant. Of the six groups, the lowest mortality was evident in the 41 patients in Penn Class A who had a simple operation, whereas the highest was seen in the 13 Penn Class C patients who underwent a complex operation (0 vs. 23.1%, p = 0.001). Conclusion:In spontaneous acute TAAD, degree of malperfusion on presentation, rather than operative complexity, was the dominant factor in early mortality.
Erdheim Chester disease (ECD) is a rare fibroinflammatory disease that affects different segments of aorta. It appears as diffuse wall thickening and periaortic accumulation of scar tissue on computerized tomography (CT). The CT scans describe the size and the external structure, with minimal description of endoluminal surface of the aorta. In this report, CT images were used to visualize the interior surface of the aorta and the response to treatment in a patient with ECD.
Diameter of the aorta is a significant contributor and predictor for complications and a fundamental parameter for intervention. It is recognized that age, sex, and ethnicity play a role in aortic size. We thus sought to determine the normal dimensions among our population.A retrospective analysis of images was done of all polytrauma patients admitted between January 2018 and December 2022 who underwent protocolized noncontrast computed tomography of the chest and abdomen to measure the aortic diameter at established reference points.There were 513 patients; the mean age was 36.5 ± 14.6 (range: 18-86), and 382 (74.5%) were males. Aortic dimensions at sinus, mid-ascending, arch, descending, suprarenal, and infrarenal aorta were 30.7 ± 3.8, 29.3 ± 4.5, 24.9 ± 3.3, 20.1 ± 3.0, 19.4 ± 2.9, and 15.3 ± 2.2, respectively. Age demonstrated a positive correlation to the diameter at the ascending, descending, and infrarenal aorta (r = 0.58, p = 0.001 [95% confidence interval, CI = 0.519; 0.634]; r = 0.69, p = 0.001 [95% CI = 0.641; 0.732]; r = 0.57, p = 0.001 [95% CI = 0.509; 0.626]) along with the length of the ascending aorta (r = 0.420, p = 0.001 [95% CI = 0.345; 0.488]; r = 0.536, p = 0.001 [95% CI = 0.471; 0.595]; r = 0.476, p = 0.001 [95% CI = 0.406; 0.540), respectively. There was a positive correlation of aortic diameters to body mass index (BMI), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Females had smaller dimension at the reference points, but without any statistical significance. There were 50 (9.8%) patients with bovine aortic arch and 10 (1.9%) with separate origin of left vertebral artery.Normal values of the diameter of the aorta for a South Asian population are provided. Diameter is affected by age, length of the ascending aorta, BMI, SBP, and DBP. This study suggests that the aorta size is smaller in the South Asian population than the referenced Western population, more significantly for distal descending and abdominal aorta and that ethnicity plays a role in determining aortic dimensions.
Two pregnant siblings presented with thoracic aortic dissection during the second trimester. A pathogenic MYH11 was identified following the first sibling's diagnosis. The second sibling, previously known to be at risk but lost to follow-up, reengaged during pregnancy, tested positive for the familial variant, and dissected before her initial evaluation. This case highlights the importance of genetic diagnosis, surveillance, and multidisciplinary care in managing heritable thoracic aortic disease during pregnancy.
We aim to better define the association between thoracic aortic aneurysm (TAA) and giant cell arteritis (GCA), thereby enhancing cross-diagnosis, monitoring, and therapy. Literature review: We used a two-step search approach to the available literature on the relationship between TAA and GCA. First, databases including PubMed, Web of Science, and Embase were searched. Additionally, relevant studies were identified through secondary sources including references of initially selected articles. Retrospective cohort study: We identified patients at our institution who were diagnosed with both TAA and GCA from January 1980 through December 2024. Descriptive statistics were used to support the association between these two diseases described in the literature. The literature review disclosed an increased incidence and relative risk of TAA among patients with GCA. GCA patients experienced progressive aortic enlargement, which may be due to vascular inflammation and disruption of elastin and collagen fiber biology in the vessel wall, resulting in mechanical weakness. Progressive aortic enlargement, including the aortic annulus, often results in aortic insufficiency (AI); in surgery, complete aortic replacement is recommended. Predictors of aneurysmal disease included AI and severe inflammatory response at the time of GCA diagnosis, as well as risk factors such as male sex, hypertension, hyperlipidemia, coronary disease, diabetes, and smoking. The investigation at our institution revealed that among 2,344 patients with GCA, 72 developed TAA, an incidence of 3.1%. Among those, 61 (84.7%) had an ascending aortic aneurysm, 5 (6.9%) had a descending aortic aneurysm, and 6 (8.3%) had both. Of these, 33 (45.8%) were male, 66 (91.7%) had hypertension, 44 (61.1%) were former or current smokers, 16 (22.2%) had diabetes mellitus, 66 (91.7%) had hyperlipidemia, 31 (43.1%) had coronary disease, 33 (45.8%) had concomitant polymyalgia rheumatica, and 21 (29.2%) had AI at the time of GCA diagnosis. Our study highlights a 3.1% incidence of TAA in GCA patients, with hypertension, smoking, and hyperlipidemia as the most common additional risk factors. Ascending aortic aneurysms were the most frequent, occurring in 84.7% of TAA in GCA cases. These findings emphasize the importance of monitoring for TAA in the GCA population.
Acute aortic dissection (AAD) is a potentially lethal condition with a high rate of misdiagnosis during the initial evaluation. In addition to established clinical variables, previous studies have consistently demonstrated a relationship between full blood count (FBC) and its various differentials with acute aortic syndromes, even identifying patients with worse outcome. Although FBC is a simple, inexpensive and routinely performed test, it is easily overlooked by clinicians. However, nearly all components of FBC, including white blood count, red blood cells, and platelets, may contribute to the underlying pathogenesis of AAD and therefore, we should fully explore and pinpoint precisely their potential diagnostic or prognostic performances. Herein, we summarize the results of such studies and discuss controversies regarding utility in future clinical practice.
Acute type A aortic dissection (ATAAD) is traumatic and life-threatening involving a split of the intima media along a variable length of the aorta from aortic root to aortic bifurcation. The pathology results in a local and systemic inflammatory process with elevated inflammatory markers observed at hospital admission. This systematic literature review aimed to compare the effectiveness of admission inflammatory markers in predicting adverse outcomes in postoperative ATAAD patients. Eligibility criteria included studies reporting postoperative outcomes or receiver operating characteristic results stratified by routine admission markers of inflammation in ATAAD patients. The study protocol was registered with PROSPERO (CRD42022366509). Following abstract and full-text screening, 79 studies were included in the analysis, with 39 included in the meta-analysis. Meta-analyses using random effects models of white blood cell count, neutrophil count, and neutrophil to lymphocyte ratio stratified by survival indicated that levels were significantly lower in survivors than nonsurvivors. The mean difference for white blood cell count was 1.51 (confidence interval [CI = 1.07, 1.95]), neutrophil count 1.50 [CI = 1.05, 1.95], and neutrophil to lymphocyte ratio 3.45 [CI = 2.50, 4.41]. Similarly, survivors had lower C-reactive protein levels than nonsurvivors (standardized mean difference = 0.5227 [CI = 0.1781, 0.8672]). Conversely, lymphocyte counts were higher in survivors than nonsurvivors (mean difference = -0.12 [CI = -0.18, -0.06]). All models had significant heterogeneity despite using random effects models, likely due to the multitude of presentations. Hierarchical summary receiver operating characteristic models were performed for neutrophil-to-lymphocyte ratio and C-reactive protein and showed similar sensitivity at detecting mortality in ATAAD patients for each fixed specificity. Data showed that deranged inflammatory markers are associated with poorer outcomes in ATAAD; however, none of these measures provide suitable prognostic markers alone. Continued development of multifactorial risk scores, including inflammatory markers and other factors, such as thrombotic measures, may enable clinically relevant prognostic tools and risk stratification.
Deep hypothermic circulatory arrest (DHCA) is associated with coagulopathy but facilitates aortic arch surgery. Conflicting data suggest moderate hypothermic circulatory arrest (MHCA) may reduce transfusion requirements. We hypothesized MHCA would reduce transfusion requirements.We studied patients undergoing aortic hemiarch surgery for nondissected, aneurysmal disease from July 2014 to May 2023 utilizing a multicenter collaborative. Patients were stratified by DHCA (14.1-20°C) and MHCA (20.1-28°C). Packed red blood cells (pRBC), fresh frozen plasma (FFP), cryoprecipitate, and platelet transfusion requirements were assessed. A negative binomial model accounting for hospital random effect was fitted to identify risk factors for increased transfusion requirements.Of the 451 patients undergoing hemiarch surgery, 373 (83%) had MHCA and 78 (17%) had DHCA. MHCA patients had shorter cardiopulmonary bypass (135 minutes [105, 182] vs. 216 minutes [183, 263], p < 0.001) and circulatory arrest times (12 minutes [8, 17] vs. 21 minutes [16, 34], p < 0.001). MHCA patients received fewer pRBC (0 [0, 1] vs. 1 [0, 3], p < 0.001), FFP (0 [0, 3] vs. 2 [0, 4], p = 0.003), cryoprecipitate (1 [0, 1] vs. 1 [0, 2], p = 0.045), and platelet transfusions (0 [0, 1] vs. 2 [0, 2], p < 0.001). Unadjusted operative mortality was lower in the MHCA group (1.9 vs. 7.7%, p < 0.01). After risk adjustment, MHCA was associated with reduced FFP transfusion requirements (β = -0.48, SE = 0.2, p = 0.017). Increasing bypass time per minute was associated with increased pRBC (β = +0.01, 95% CI = 0.006-0.013, p < 0.001), FFP (β = +0.006, 95% CI = 0.004-0.009, p < 0.001), cryoprecipitate (β = +0.008, 95% CI = 0.005-0.01, p < 0.001), and platelet transfusions (β = +0.009, 95% CI = 0.006-0.011, p < 0.001).MHCA was associated with decreased mortality and FFP transfusions in aortic hemiarch repair. MHCA may mitigate transfusion needs via shorter cardiopulmonary bypass time compared with DHCA.
Prior research provided evidence that diabetes mellitus (DM) may convey protection to patients with abdominal aortic aneurysm (AAA) and/or thoracic aortic aneurysm (TAA).We sought recent publications that support or elaborate on this concept using PubMed and Cochrane, searching for publications that combine the search terms "aortic aneurysm" and "diabetes mellitus." We collate and summarize evidence from the literature on this topic.We examined pertinent data on AAA, TAA, and aortic aneurysms in general (AA). Patients with DM have lower risk of developing AAA and a lower rate of growth of AAA. Patients with DM have a lower risk of mortality following hospitalizations for AA. That said, however, patients with DM who undergo AAA repair show higher risk of mortality. Patients with DM have lower aneurysm diameter and lower homocysteine and D-dimer levels. Research is emerging regarding a possible genetic explanation: the gene PSMD12 may play a role in the connection between AAA and DM. Patients with AAA taking diabetic medication metformin show reduced rate of growth of AAA as well as decreased mortality and complications. In TAA, however, no statistically significant differences in mortality or complications are consistently found. We find positive evidence to support the concept that diabetes does confer protection from AAA rupture. Current data does confirm significant protective effect for TAA.We confirm that metformin does exert protective properties. Diabetic protection against AAA may be mediated via Laplace's Law, as diabetic aortas have thicker walls, thus decreasing wall tension.
Valve-sparing root replacement (VSRR) is an alternative to traditional valve-replacing root replacement. We examined early- and mid-term outcomes after VSRR. We performed a retrospective review of a prospectively maintained aortic registry. All patients undergoing VSRR from 2005 to 2023 were included. Statistical analysis was performed in R version 4.3.1. Kaplan–Meier curves were used to describe mortality and freedom from mortality, aortic insufficiency (AI) > 1 + , and aortic valve-related reoperation. Eighty-one patients underwent VSRR, 59 (72.8%) through full sternotomy (FS) and 22 (27.2%) through upper hemisternotomy. There were no cases of AI > 1+ in the perioperative period, 1 (1.2%) stroke, and no in-hospital mortality. Mean intensive care unit and hospital stay were 3 and 7 days, respectively. Mean follow-up time was 8 years. Freedom from all-cause mortality at 1, 5, and 10 years was 100, 96.6, and 94.4%, respectively. Composite freedom from reoperation, recurrence, or mortality at 1, 5, and 10 years was 98.8, 92.1, and 87.3%, respectively. With careful preoperative selection, VSRR is a durable procedure for patients with aortic root aneurysm.
This study investigates the evolution of aortic valve function following supracoronary ascending aorta replacement (SCR) for acute type A aortic dissection (ATAAD). Factors contributing to aortic valve stability and progression of aortic valve insufficiency (AI) were examined. Patients who survived SCR for ATAAD between 2000 and 2021 were included. Univariable analyses to identify risk factors for AI grade ≥ 2 were performed, including anatomical parameters, perioperative findings, and follow-up root diameters. Evolution of aortic root dimensions was also investigated. Seventy-eight patients were included. AI grade ≥ 2 was observed in 20 (29.4%) patients during follow-up. Cumulative incidence of AI grade ≥ 2 was 4.7 ± 2.2%, 7.9 ± 3.4%, and 15.1 ± 5.5% at 1, 5, and 10 years, respectively. Aortic root reoperation was performed in three patients (4.0%) within 3 years of the index operation. Significant predictors of AI grade ≥ 2 included preoperative AI grade ≥2 (p = 0.037, odds ratio [OR] 1.46, 95% confidence interval [CI]: 1.02–2.09) and significant preoperative AI grade ≥ 2 in presence of at least two dissected sinuses (p = 0.039, OR: 2.88, 95% CI: 1.05–7.89). Diameters of the sinus of Valsalva (p < 0.001), sinotubular junction (p < 0.001), and ascending aorta graft (p < 0.001) increased over time. Absence of sinus of Valsalva ≥ 45 mm was 90.9, 84.9, and 80.3% at 1, 5, and 10 years, respectively. Preserving the aortic valve after ATAAD offers a viable long-term surgical option with a low need for proximal root reoperations in patients without aortic root dilatation. Significant preoperative AI, particularly in presence of extensive root dissection, are significant predictors of late AI grade ≥ 2, suggesting valve-sparing root replacement in these patients.
Valve-sparing root replacements are increasingly being performed in patients with bicuspid aortic valve (BAV) and root aneurysm. This study aims to compare the outcomes of patients who underwent root remodeling versus root reimplantation. From 2000 to 2022, 206 adults with BAV and root aneurysm (mean age: 47 ± 12 years, 183 [89%] male) underwent root remodeling (n = 32) or reimplantation (n = 174) at Cleveland Clinic. Compared with remodeling, patients in the reimplantation group had more aortic regurgitation (severe 61/174 [35%] vs. 3/32 [9.4%]) and smaller aortic roots (sinus diameter: 4.3 ± 0.56 vs. 4.6 ± 0.47 cm). Operative mortality and morbidity, durability, and time-related mortality were compared. Patients in both groups underwent additional aortic valve repair (reimplantation vs. remodeling group: figure-of-8 hitch-up stitch 10/174 [5.7%] vs. 14/32 [44%], p < 0.001; cusp plication 91/174 [52%] vs. 11/32 [34%], p = 0.06). Compared with the remodeling group, aortic clamp time was longer in the reimplantation group (median 136 vs. 76 minutes, p < 0.001). Two in-hospital reoperations occurred after remodeling from valve dysfunction. One operative death occurred in each group. At 5 years, severe aortic regurgitation was 16% after remodeling versus 5.0% after reimplantation (p = 0.06), mean gradient 11 versus 10 mm Hg (p = 0.12), aortic valve reoperation 23% versus 6.0% (p = 0.14), and survival 97% versus 95%, respectively (p = 0.71). Both root remodeling and reimplantation can be safely performed in patients with BAV and root aneurysms with similar midterm outcomes. Although root remodeling is a shorter surgery, less late aortic valve regurgitation and fewer valve reoperations lead us to recommend root reimplantation.
