Objective To compare the outcomes between surgical and conservative treatment of aorto-esophageal fistula after descending aortic repair. Methods Between January 2019 and January 2024, we treated 35 patients with aorto-esophageal fistula after descending aortic repair. Patients were assigned to conservative (n = 14) or surgical (n = 21) management. Surgical strategies included in situ descending thoracic aortic replacement (n = 2); two-stage aortic surgery with (n = 12) or without (n = 4) esophageal repair—first stage: combined median sternotomy and upper midline laparotomy with a four-branch Dacron graft interposition between the ascending and abdominal aortas, debranching of the supra-aortic trunks, and aortic arch transection proximal to the innominate artery; second stage: left intercostal thoracotomy with excision of the infected descending aorta, stent graft, and surrounding mediastinal tissue; single-stage aortic surgery (n = 1); and isolated esophageal repair (n = 2). Results Mean age was 54.5 ± 10.2 years, and 31 (88.6%) patients were male. Prior aortic repair included thoracic endovascular aortic repair in 27 (77.1%), total arch repair in 2 (5.7%) and combined total arch repair with thoracic endovascular aortic repair in 6 (17.1%).Early mortality was 50.0% (7/14) in the conservative group versus 14.3% (3/21) in the surgical group (P = 0.053). Causes of early death primarily included aortic rupture and sepsis with multiorgan failure. follow-up was 100% complete at median 30 months (interquartile range 3.3–74). All conservatively managed patients died within 1.5 years. Late death occurred in 6 patients of the surgical group (28.6%), and all survivors successfully resuming normal oral feeding. The 1-, 3-, and 5-year survival rates were significantly higher in the surgical group (71.4%, 58.4%, and 48.7%) compared to the conservative group (14.3%, 0%, and 0%; P < 0.001). Notably, patients undergoing two-stage aortic surgery achieved a favorable 5-year survival of 65.6%. Conclusions The two-stage aortic surgery with esophageal repair yielded favorable outcomes in the management of aorto-esophageal fistula secondary to descending aortic repair.

Background:Aortoesophageal fistula (AEF) is a relatively rare and life-threatening condition, and the optimal surgical treatment for secondary AEF following thoracic endovascular aortic repair (post-TEVAR AEF) remains controversial. This study aimed to summarize the clinical efficacy of aortic arch debranching combined with extra-anatomic bypass for the treatment of post-TEVAR AEF. Methods:The clinical data of 16 patients who underwent surgical treatment for post-TEVAR AEF at our institution from 30 June 2019 to 30 June 2024 were retrospectively reviewed. Aortic arch debranching and extra-anatomic aortic bypass under general anesthesia were performed for most patients. Empirical antibiotics were administered for 6-8 weeks. The acute and long-term outcomes were summarized. Results:Stent-related infection leading to AEF occurred at a median interval of 30 months after the initial TEVAR surgery. All patients presented with recurrent fever preoperatively; blood bacterial cultures were positive in nine patients (56.25%) and negative in seven patients (43.75%). The median operative time was 460.5 (433.5, 543.5) minutes, and the median intensive care unit stay was 7 (5.25, 31.75) days. No intraoperative mortality was observed in this cohort. During the follow-up period, three patients developed recurrent AEF accompanied by severe infection. Four patients died postoperatively, including one who died of thoracic aortic rupture and hemorrhage within 3 months postoperatively, and three others died of multiple organ failure at 4-10 weeks after surgery. The remaining 12 patients achieved favorable postoperative recovery without the need for prolonged antibiotic therapy. Conclusion:Aortic arch debranching and extra-anatomic bypass from the ascending aorta to the proximal abdominal aorta yields favorable acute and long-term outcomes for patients with post-TEVAR AEF.

This report describes the innovative use of computational fluid dynamics (CFD) in managing a case in a 17-year-old male patient with anomalous origin of the right pulmonary artery from the ascending aorta, presenting with hemoptysis. Given the high risk of late repair, patient-specific CFD models were created. Preoperative simulation replicated invasive pressure measurements, and a virtual surgery predicted favorable outcomes. The patient underwent successful surgical reimplantation. Postoperatively, CFD findings at 1 week and 4 months closely matched the virtual prediction and were validated by synchronous four-dimensional flow MRI, demonstrating progressive hemodynamic normalization. Our experience suggests that CFD is a valuable adjunct for surgical planning and longitudinal assessment in complex congenital heart disease. Keywords: Congenital, Cardiac, CT-Angiography, Hemodynamics/Flow Dynamics, MR-Imaging, Pulmonary Arteries, Aorta Supplemental material is available for this article. ©The Author(s) 2026. Published by the Radiological Society of North America under a CC BY 4.0 license.

OBJECTIVE:We seek to evaluate our experience with the management of type A aortic dissection (TAAD) during pregnancy or in the postpartum period over 25 years. METHODS:From 1998 to 2023, our team managed 60 pregnant women (mean age, 31.4 ± 5.0 years) who sustained TAAD at mean of 30.3 ± 8.5 gestational weeks (GWs), including 27 in the third trimester (45.0%) and 13 during the postpartum period (21.7%). Marfan syndrome (MFS) was seen in 39 patients (65.0%) with 13 (21.7%) having a positive family history. Before operation, aortic root diameter averaged 53.6 ± 17.1 mm, which was significantly larger in MFS patients than non-MFS patients (57.0 ± 17.0 mm vs 47.0 ± 15.0 mm, P = .019). Management strategy was based on GWs (ie, surgical versus medical treatment, surgery first, or delivery first). RESULTS:One patient was treated medically (1.7%), and 59 were treated surgically (98.3%). Management strategies were single-stage delivery and aortic repair at a mean of 32.4 ± 4.5 GWs in 29 (48.3%); delivery first at 35 ± 8 GWs in 18 (30%), followed by aortic repair after a median of 6.2 days, and aortic repair first at 18.6 ± 6.3 GWs in 12 (20%), followed by delivery after a median of 9.5 days. Maternal and fetal mortality rates were 100% (1/1) and 100% (1/1), respectively, with medical therapy, 11.1% (2/18) and 11.1% (2/18) with delivery first, 3.4% (1/29) and 22.6% (7/31) with single-stage delivery and aortic repair, and 16.7% (2/12) and 66.7% (8/12) with aortic repair-first strategies. Follow-up was complete in 98.1% (53/54) at a median duration of 6.7 years (interquartile range, 4.8-10.9 years). Five maternal deaths and 2 fetal deaths occurred. Eight patients underwent a total of 10 reoperations. Ten-year maternal and fetal survival rates were 79.3% and 67.7%, respectively. Eight patients (7 with MFS, 87.5%) underwent 10 reoperations at a median of 4.7 years (IQR, 2.1-9.1 years). CONCLUSIONS:For TAAD occurring after 28 GWs, adequate maternal and fetal survival can be achieved with delivery followed by aortic repair, preferably in one stage. Before 28 GWs, maternal survival should be prioritized, given the high uncertainty of fetal survival. Prophylactic aortic repair may be reasonable for women with Marfan syndrome contemplating pregnancy when the root diameter is 45 mm or even smaller.

Re-operative aortic surgery in the setting of a “frozen chest” carries a high risk of catastrophic hemorrhage during sternal re-entry. We describe a strategy using pre-sternotomy hypothermic circulatory arrest and dual arterial inflow via the right axillary and femoral arteries to enable total body perfusion (TBP). TBP allows controlled sternal entry, followed by rapid restoration of combined cerebral and systemic perfusion through simultaneous dual inflow during reconstruction. This approach minimizes ischemic burden, provides perfusion flexibility across operative phases, and facilitates complex aortic repair.

OBJECTIVES:Type B aortic dissection (TBAD) is rare in patients aged ≤30 years, and data on this population remain limited. This study aimed to characterize the underlying aetiology, and outcomes of invasively treated young patients with TBAD, with a focus on the impact of heritable thoracic aortic disease (HTAD). METHODS:A retrospective multicentre analysis was conducted across 19 international aortic centres, including 139 patients aged ≤30 years with TBAD. Patients with chronic TBAD (n = 42) were excluded for the final analysis. The cohort was classified as uncomplicated (n = 86) or complicated (n = 53) TBAD. Clinical, radiologic, intraoperative, and postoperative data were collected using standardized forms. Outcomes were compared between subgroups defined by TBAD complexity, HTAD status, and surgical strategy. Kaplan-Meier and Andersen-Gill analyses were used for survival and recurrent aortic intervention, respectively. RESULTS:Mean follow-up time was 6.5 years. HTAD was identified in 57% of patients. Most presented with uncomplicated TBAD (62%), while high-risk uncomplicated cases were uncommon. Endovascular repair was predominant in complicated TBAD, while open repair was more frequent in uncomplicated cases. Early mortality was low (n = 3), and mid-term survival was excellent across all subgroups. HTAD was a significant predictor of recurrent aortic interventions (HR = 3.3, P = .004). No significant differences were observed in survival or reintervention rates between uncomplicated and complicated TBAD or between operative strategies. CONCLUSIONS:In young patients, TBAD predominantly occurs in the context of HTAD. Both open and endovascular repair are associated with excellent early outcomes and mid-term survival. However, HTAD remains a significant predictor of recurrent aortic interventions.

BACKGROUND AND AIMS:The management of acute type A aortic dissection (ATAAD) has evolved considerably over the decades and a more aggressive approach with extended arch repair has been increasingly adopted in the past 20 years. This study aims to evaluate the early and long-term outcomes of frozen elephant trunk and total arch replacement (FET + TAR) technique in patients with ATAAD. METHODS:From April 2003 to December 2014, 850 patients with ATAAD (mean age 46.5 ± 10.7 years; 169 women [19.9%]; 136 with malperfusion syndrome [16.0%]) underwent FET + TAR at our center. Aortic root or valve procedures were performed in 456 patients (53.6%). The early and long-term outcomes of FET + TAR were analysed and compared to hemiarch repair in 72 propensity-matched pairs. RESULTS:Operative mortality was 8.4% (71/850). Spinal cord injury occurred in 2.5% (21/850), stroke in 3.5% (30/850), re-exploration for bleeding in 5.6% (48/850) and acute kidney injury in 8.7% (74/850). Follow-up was complete in 99.2% (773/779) at mean duration of 12.5 ± 4.0 years (range .2-22.0). There were 153 late deaths and 90 reoperations at median 7.5 and 5.2 years (interquartile range 4.4-9.6 and 1.2-9.7), respectively. Cerebrovascular accident (hazard ratio [HR] 2.34; P = .031) and visceral ischaemia (HR 4.12; P = .005) were risk factors of late death. At 20 years, survival and freedom from reoperation were 70.0% and 85.4% (95% confidence interval [CI], 65.8%-74.0% and 80.1%-89.4%), respectively. In competing risks analysis, the incidences were 25%, 13% and 62% for death, reoperation and reoperation-free survival at 15 years, respectively. Compared to hemiarch repair, FET showed similar operative mortality (6.9% vs 4.2%, P = .719) and lower incidences of late adverse events (LAE), including death, reoperation and distal aortic dilation (16.4% vs 33.8%, P = .048), with significantly higher freedom from LAE at 20 years (78% vs 45.6%; 95% CI, 58.8%-89.0% vs 27.7%-61.8% P = .042). CONCLUSIONS:In this series spanning two decades, the FET + TAR technique achieved satisfactory long-term survival and freedom from reintervention in patients with ATAAD, showing lower risk of late death, reoperation and distal aortic dilation compared to hemiarch repair. These results argue favourably for the use of FET technique in ATAAD repair.

Background:The Sun procedure has been widely adopted across China for the treatment of acute type A aortic dissection (ATAAD). Although favorable outcomes have been reported from high-volume centers, institutional series offering detailed early data using modern operative protocols remain limited. This study is structured in two parts: first, a review of the literature on the development and reported outcomes of the Sun procedure in different aortic populations across China; and second a presentation of contemporary operative characteristics and early outcomes in patients undergoing the Sun procedure for ATAAD at a single institution. Methods:A retrospective analysis was conducted on 729 consecutive patients with ATAAD treated at DeltaHealth Hospital from 2016 to 2024. Among these, 573 patients (78.6%) underwent total arch replacement with frozen elephant trunk (FET) using the Sun procedure. Baseline characteristics, operative variables, and early outcomes were analyzed. Neurologic, renal, pulmonary, and systemic complications are reported. Results:The mean age of patients was 52.7±14.1 years, and 73.5% were male. Cardiac tamponade was present in 19.1% of patients at presentation. The history of cerebrovascular disease was noted in 4.1%, 3.4% had chronic kidney disease and 13.6% had Marfan syndrome. In-hospital mortality was 4.1%. Major complications included stroke (10.2%), spinal cord injury (SCI) (2.6%), acute renal failure (8.4%), gastrointestinal complications (4.1%), and reoperation for bleeding (14.3%). Sternal dehiscence and limb ischemia occurred in 1.8% and 1.6% of patients, respectively. Outcomes were achieved despite the presence of significant preoperative malperfusion syndromes, cerebral (8.2%), coronary (13.6%), and spinal cord malperfusion (2.2%). Conclusions:The Chinese experience with the Sun procedure highlights the potential of standardized surgical strategies in complex aortic disease. This dataset affirms the technique's safety, durability, and adaptability across acute, chronic, and heritable aortic pathologies.

Objective:This study aimed to evaluate the safety and durability of transcatheter closure of anastomotic leak (AL) after ascending aortic (AAo) surgery. Methods:From 2016 to 2021, we performed transcatheter closure for 22 patients aged 56.9 ± 12 years (19 male, 86.4%) who sustained anastomotic leak in the ascending aorta (AAoAL) after AAo surgery. Access and device were selected according to the presence of a patent Cabrol (perigraft-to-right atrium) shunt (n = 16, 72.7%) and leak size. Results:Fifteen patients had tricuspid regurgitation (TR; 68.2%), 13 were symptomatic (59.1%), and 11 were in the New York Heart Association (NYHA) functional class III/IV (50%). Mean AAoAL diameter was 3.3 ± 1.5 mm. Mean procedural time was 141 ± 53 minutes. Procedural success rate was 86.4% (19/22, 14 with Cabrol shunt). AAoAL was directly closed or coiled in 12 patients. Follow-up was complete in 100% at a mean duration of 4.9 ± 1.1 years (range 3.6-8.1). All patients were alive, and two underwent reoperation. Freedom from death and reoperation was 94.7% at 2 years and 89.5% through 8 years. AAoAL was obliterated in 11, while a trace residual shunt was seen in 8 patients. The aorta at the leak shrank significantly in all (49.1-41.4 mm, p = 0.010). Patients with Cabrol shunt showed a significant shrinkage of the right atrium (46.9 ± 8.8 mm vs. 39.1 ± 8.2 mm, p = 0.030) and right ventricle (41.4 ± 4.7 mm vs. 30.4 ± 6.2 mm, p < 0.001), along with improved heart function (NYHA class III 4/12, IV 5/12 vs. class III 4/12, IV 0/12, p = 0.032) and alleviation of TR (moderate 6/14, severe 3/14 vs. moderate 2/14, severe 1/14, p = 0.081). Conclusion:Transcatheter closure may be a feasible, safe, and effective approach to anastomotic leak after ascending aortic surgery in selected patients, which can achieve favorable short- to midterm outcomes.

Background:The open anastomosis technique is a classic procedure for treating extended ascending aortic aneurysms, but hypothermic circulatory arrest is unavoidable, which increases the risk of organ injury. The aortic arch-clamping (AAC) technique is an alternative treatment. This study aimed to evaluate the efficacy of the AAC technique in patients with ascending aortic aneurysms extending to the proximal arch. Methods:From January 2015 to February 2022, 230 patients with ascending aneurysms extending to the proximal arch underwent surgical intervention. Based on the type of distal ascending aorta surgery, the patients were divided into the AAC group (n=117 cases) and the open distal anastomosis (ODA) group (n=113 cases). The prognosis of 67 matched pairs was compared after 1:1 propensity score matching (PSM). Results:After PSM, the baseline data were similar between the AAC and ODA groups. In the AAC group, the cardiopulmonary bypass duration was significantly lower (median 120 vs. 156 min, P<0.001). The incidences of acute kidney injury (AKI), transient neurological dysfunction, and ventilation time >24 h increased significantly in the ODA group (32.8% vs. 7.5%, P=0.001; 9% vs. 0%, P=0.04; 19.4% vs. 6%, P=0.04, respectively). Multivariable logistic regression analysis showed that the AAC approach was an independent protective factor for composite adverse events [odds ratio (OR): 0.05, 95% confidence interval (CI): 0.01-0.39, P=0.005], ventilation time >24 h (OR: 0.33, 95% CI: 0.12-0.92, P=0.03), and AKI (OR: 0.21, 95% CI: 0.08-0.54, P=0.001). There was no significant difference in midterm mortality (3.0% vs. 4.5%, P=0.44) or reintervention rates (3.0% vs. 3.0%, P=0.91) between the two groups. Conclusions:Considering its short- and mid-term efficacy, the AAC technique is an alternative technique for extended ascending aneurysms.

BACKGROUND We sought to study whether early initiation of renal replacement therapy (RRT) could reduce 90-day mortality and improve clinical outcomes in patients with acute kidney injury after acute type A aortic dissection. METHODS This single-center, randomized, controlled trial enrolled acute type A aortic dissection patients with severe postoperative acute kidney injury classified as Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 and with a plasma neutrophil gelatinase-associated lipocalin level >150 ng/ mL who did not have potentially life-threatening complications directly related to renal failure. Patients were randomized equally into 2 groups: the early RRT group received RRT within 6 hours of diagnosis of KDIGO stage 2; the standard treatment group was managed with RRT initiated within 8 hours of stage 3. The primary outcome was mortality at 90 days. Secondary outcomes included in-hospital mortality, 30-day mortality, clinical evidence of organ dysfunction, duration of RRT, and intensive care unit and hospital lengths of stay. RESULTS Among 212 patients, all patients in the early group (n =106) and 100 of 106 patients in the standard treatment group received RRT. Early initiation of RRT significantly reduced 90-day mortality (30.2%) compared with standard initiation (51.9%; P = .001). In-hospital mortality was lower in the early group (24.5% vs 38.7%; P = .03), and 30-day mortality was also reduced (28.3% vs 43.4%; P = .02). Nevertheless, there was no significant difference in organ dysfunction or in intensive care unit and hospital lengths of stay. CONCLUSIONS Our results revealed that early initiation of RRT improves patient prognosis.