Abstract Background Open thoracoabdominal aortic aneurysm (TAAA)repair carries high risk of organ ischaemia.We assessed mortality, survival, and the effect of standardised organ and spinal cord protection bundle in high-risk single-centre cohort. Methods Analysis of 124 consecutive repairs (2017–2021): open 98, endovascular 26; non-elective 26; Extent II 69; redo 51. Risk factors were analysed. The bundle comprised left-heart bypass (LHB), selective coeliac and renal perfusion (Custodiol/cold blood), cerebrospinal fluid drainage (CSFD), paraspinal NIRS, cMEP, selective intercostal reimplantation. In a feasibility subset, lactate, pyruvate, and glucose CSF/MD were measured serially;lactate-pyruvate-ratio(LPR > 25) was pre-specified as a metabolic ischaemia threshold. Results In-hospital mortality was 17.7% (open 16.9%; endovascular 0.8%). Stroke 6.5%; SCI 11.3% (permanent 8.9%). Haemofiltration was required in 41.9% (permanent 4.0%). Five-year survival was 79.8%. Bundle delivery: LHB > 90%, CSFD 79.8%, coeliac/SMA perfusion 88%, renal perfusion 82%, CSFD/MD 5% (feasibility). Haemofiltration (HR 14.89, P = 0.020) and paraplegia (HR 4.30, P = 0.027) predicted in-hospital death, whereas SMA perfusion was protective (HR 0.023, P = 0.036). Serial MD showed metabolic derangement during ischaemia (rising lactate, falling glucose, LPR > 25), normalising with reperfusion. Lactate rose fivefold, peaking six hours postoperatively (P = 0.001). Intraoperative SCI (two patients with >50% cMEP reduction) was associated with 200% LPR increase. Conclusions In this high-risk Extent II, non-elective/redo cohort,multimodal protection achieved acceptable survival. Mortality was driven by renal replacement therapy and SCI, underscoring the need for rigorous spinal protocols and standardised bundles. CSF microdialysis offers actionable real-time metabolic surveillance with potential to improve outcomes.

The management of thoraco-abdominal aortic aneurysms remains challenging, particularly in patients considered unsuitable for conventional endovascular procedures due to unfavourable anatomy or unfit for traditional open surgical approaches due to comorbidities. In response to these limitations, a novel hybrid prosthesis has emerged as an alternative designed to reduce invasiveness, avoid aortic cross-clamping and avoid extracorporeal circulation. The Thoracoflo® (Terumo Aortic, Glasgow, UK) has been developed to bridge the gap between open and endovascular techniques, especially for patients with connective tissue disorders and individuals with complex anatomical challenges. In this paper, we present the use of the Thoracoflo device via a thoraco-phreno-laparotomy, offering an alternative to the previously employed medial laparotomy.

Objective To evaluate the outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD)). Methods This retrospective observational study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. All cases of NANB AAD (B 1-2 D) treated at our institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodeling were analyzed. Results Among 519 cases of acute aortic syndrome, n = 22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n = 16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly 2 days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7 (31.8%) needed emergent operation for risks of impending aortic rupture or retrograde aortic dissection extension, and 4 (26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of false lumen thrombosis (100% vs 55.5%, P = 0.033), and a significant positive aortic remodeling in zone 3 (P < 0.001) and 4 (P = 0.038) were reported in operated versus medically managed patients. Conclusions The best treatment for NANB is not established. We advocate for medical stabilization with an operative approach that favors open surgery in the acute post dissection period, promotes aortic remodeling, and carries acceptable risk in centers where FET is performed routinely.

Background: Non-A non-B (NANB) aortic dissections (ADs) are uncommon (3%-11% of all ADs), so, frequently, they are unrecognized and classified as type B dissections. Methods: We reviewed the literature and our own experience to summarize the presentation and treatment of NANB dissection. Results: Currently defined as a dissection with a primary tear in the arch (Ishimaru zone 1 or 2) or in Ishimaru zone 3 and retrogradely extending into the arch they indicate an heterogenous group of diseases that may deeply differ in terms of clinical and anatomical presentation. Affected patients tend to be younger (57 years vs 65 and 67, years respectively) when compared with type A and B ADs and the clinical presentation and evolution seem to be frequently complicated (<= 88% of cases) with signs of malperfusion (29%) or risk of impending rupture (6%). Nonoperative management seems possible in only a small percentage of NANB cases with most patients undergoing intervention in the acute or subacute phase. However, because of the variability of the dissection anatomy and extent, the type and timing of treatment may vary, and there is no standardized treatment pathway. Despite its preferability, anatomical or goal-directed treatment does not yet represent the standard of care. The reported data are heterogenous, and thus it is difficult to compare the outcomes achieved with surgical and endovascular strategies. Taken at face value, the published papers demonstrate that the 30-day mortality rate is increased in patients treated medically vs those who undergo intervention (14.0% vs 3.6%), but populations included in these publications are not comparable: Most studies only focus on a single approach, with small sample sizes and limited detail on the anatomical features of the dissection. When an intervention is needed, several strategies have been adopted so far, including open aortic arch replacement or frozen elephant trunk, thoracic endovascular aortic repair with chimney stent graft or hybrid procedures with surgical rerouting of supra-aortic branches and thoracic endovascular aortic repair. After intervention, the postoperative stroke rate ranges between 0% and 12.5%, and postoperative myocardial infarction is described in up to 2.8%; aortic-related reintervention during follow-up are reported to be up to 43.6% in the operative group. Conclusions: NANB dissections are complex and can be considered a high-risk presentation of type B dissections. Because of the heterogeneity and the lack of exhaustive data, a prospective study would be pivotal to provide more substantial evidence for the standardize application of surgical/medical approaches in this subgroup of patients for whom immediate and long-term outcomes deeply relay on the selection criteria and radiological findings at the initial onset. (JVS-Vascular Insights 2025;3:100251.)

OBJECTIVES:Acute Type A aortic dissection (ATAAD) repair is a high-risk procedure with significant in-hospital mortality. This study evaluates the impact of implementing an On-call Specialist Aortic Rota on ATAAD repair outcomes. METHODS:Retrospective analysis of prospectively collected data for all ATAAD repairs performed in our centre between January 2015 and October 2023 (n = 406). In September 2020, an On-Call Specialist Aortic Rota was introduced, requiring surgeons to perform at least 10 major aortic cases and 4 ATAAD repairs annually. Outcomes were compared between the pre-Rota (Group A) and post-Rota (Group B) implementation groups. RESULTS:Preoperative characteristics were similar between groups (mean age 59.7 ± 14 years, 68% male). In multivariable analysis, rota implementation was associated with lower in-hospital mortality (adjusted OR 0.60; 95% CI, 0.36-1.00; P = .049). Unadjusted mortality was 25% pre-Rota vs 16% post-Rota (P = .033). Group B had a higher rate of aortic root replacement (44% vs 35%, P = .008), lower ascending aorta and hemiarch replacement (40% vs 53%, P = .013) and showed a trend towards more extensive distal aortic repairs: total arch replacement (27% vs 20%, P = .139) and frozen elephant trunk (20% vs 14%, P = .171). Postoperative complications, including permanent stroke (7.9% vs 9.3%, P = .250) and continuous renal replacement therapy (9.8% vs 12.3%, P = .196), were comparable between groups, while tracheostomy rates were significantly lower in Group B (5.2% vs 9.7%, P = .036). CONCLUSIONS:The period after introducing an On-Call Specialist Aortic Rota was associated with lower in-hospital mortality (adjusted OR 0.60; 95% CI, 0.36-1.00) and accompanied by a practice-pattern shift towards more extensive repairs. Given the observational design and potential for residual confounding and calendar-time bias, these findings should be viewed as associative rather than causal and require confirmation in multicentre studies with longer follow-up. CLINICAL TRIAL REGISTRY NUMBER:CEU/2019/11118.

Ischaemic spinal cord injury remains a significant challenge in thoracoabdominal aortic repairs. Modern techniques have reduced spinal cord injury rates yet managing patients during and after thoracoabdominal aortic repairs remains complex. This article outlines our comprehensive approach to the prevention of spinal cord injuries in open thoracoabdominal aortic repair operations, focusing on the placement of cerebrospinal fluid drain and intraoperative strategies to enhance spinal cord protection. Preoperative planning involves thorough patient assessment, prehabilitation and nutritional support, detailed imaging review, thorough operative planning and patient blood management. Intraoperative measures include the use of neuromonitoring techniques like near-infrared spectroscopy and motor evoked potentials, as well as cerebrospinal fluid drainage together with blood pressure management to optimize spinal cord perfusion. Postoperative management focuses on maintaining haemodynamic stability with high mean arterial pressure, along with close monitoring and management of the cerebrospinal fluid drain to improve spinal cord perfusion. Additionally, thromboelastography-guided strategies are crucial for optimizing coagulation and addressing postoperative bleeding complications. The goal of this multifaceted approach is to minimize the risk of spinal cord injury, thereby improving patient outcomes and reducing the incidence of postoperative paraplegia. Our video tutorial shows some of our preoperative and intraoperative techniques for spinal cord protection in thoracoabdominal aortic repairs.

Background: To investigate impact of frozen elephant trunk (FET) on long-term distal aortic remodeling in acute A aortic dissection (AAD) according to the latest recommended standards from the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS). Methods: Clinical data and imaging of patients who underwent FET to treat acute AAD over the last 8 years were retrospectively reviewed. Patients were included if a pre and postoperative computed angio tomographies at least 30 days from surgery was available for comparison. Contrasted postprocessed imaging were analyzed with Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA) to analyze long-term positive aortic remodeling, false lumen thrombosis, and aortic expansion according to the SVS or STS recommendations. Secondary endpoints were the rate of in-hospital and long-term mortality, spinal cord ischemia (SCI), and aortic-related reinterventions. Results: Out of 75 patients who underwent FET for type A AAD, n- 41 (54.6%) were included. Significant positive aortic remodeling was reported in Ishimaru zone 1-4 but not in visceral or infrarenal aorta (P < 0.001), and the overall rate of false lumen thrombosis was 95.1% (n- 39). Aortic expansion rates were as follows: 4.9% in zones 1-4, 8.3% in zones 5-6, and 15% in zone 7. The rates of in-hospital mortality and long-term mortality were 7.3% (n- 3) and 9.7% (n- 4), respectively. At a median follow-up of 11 months (range 1-141, reintervention rate was 17.1%. Conclusions: We report positive aortic remodeling of the distal thoracic aorta in patients who underwent FET for acute AAD according to the SVS or STS reporting standards. The positive effect on the distal aorta is limited to the thoracic segments but not in the visceral aorta.

OBJECTIVES:Surgical repair of Type A aortic dissection (TAAD) requires exclusion of the primary entry tear and reestablishment of flow into the distal true lumen. Provided that the majority of tears occur within the ascending aorta (AA), replacing only that segment seems a safe option; however, this strategy leaves the root susceptible to dilatation and need for reintervention. We aimed to review the outcomes of the two strategies: aortic root replacement (ARR) and isolated ascending aortic replacement.METHODS:Retrospective analysis of prospectively collected data for all consecutive patients who underwent repair of acute TAAD at our institution from 2015 to 2020 was conducted. Patients were divided into two groups: (1) ARR and (2) isolated AA replacement as index operation for TAAD repair. Primary outcomes were mortality and need for reintervention during the follow-up.RESULTS:A total of 194 patients were included in the study; 68 (35%) in the ARR group and 126 (65%) in the AA group. There were no significant differences in postoperative complications or in-hospital mortality (23%; p = 0.51) between groups. Seven patients (4.7%) died during follow-up and eight patients underwent aortic reinterventions, including proximal aortic segments (two patients) and distal procedures (six patients).CONCLUSION:Both aortic root and AA replacement are acceptable and safe techniques. The growth of an untouched root is slow, and reintervention in this aortic segment is infrequent compared with distal aortic segments, hence preserving the root could be an option for older patients provided that there is no primary tear within the root.

Open surgery remains the gold standard for the treatment of the thoracoabdominal aorta. The rising number of endovascularly treated patients comes with an increase in the number of patients who require secondary open interventions due to the complex nature of the aortic disease or to treat endovascular complications. We describe our current approach to secondary open extent II thoracoabdominal aortic repair in patients with prior endovascular repair. In this case report, we show two different cases that exemplify this scenario.

The development of the frozen elephant trunk (FET) prosthesis has revolutionised how we treat some of the most complex aortic pathology, including in the emergency setting of acute type A aortic dissection. The design of the prosthesis is fundamental to the success of the procedure in combination with the surgeon's skill in interpreting the pre-operative scan and procedural planning to juggling the technical aspects of the deployment and reimplantation of the supra-aortic vessels. Furthermore, organ protection strategies and techniques to reduce the complications of neurological and renal impairment are paramount. This article focuses on the Thoraflex Hybrid prosthesis including the evolution of the concept, design features unique to the device and surgical technique including fundamentals of sizing and implantation steps with illustrations. The Thoraflex Hybrid prosthesis provides an ergonomic and neat delivery system with a trusted gelatin coated surgical graft material making implantation and use as straightforward as possible. These features have meant that the device is a market leader in the field of FETs with outcome data and implant figures to support its efficacy globally. The success of the device is also reflected in the literature. For example, in the UK study from Mariscalco et al., the mortality of FET implantation in acute type A dissection, of which most were using the Thoraflex device, was only 12%. This is comparable to leading centres in Europe with the inherent advantage of improving long-term outcomes in addition. Of course, this strategy is not appropriate in all cases and precise judgement of when to deploy a FET in both the emergency and elective setting is key to achieving good outcomes.

Clinical vignetteHerein, we illustrate different techniques for intercostal artery (ICA) reimplantation during thoracoabdominal aortic (TAA) surgery (1).Case 1 (loop graft): 23-year-old female with Marfan syndrome who presented with a type B aortic dissection during pregnancy, managed conservatively.On surveillance, the proximal descending diameters expanded significantly, and an extent II TAA repair from distal to left subclavian artery (LSA) to infrarenal aorta was planned.The proximal clamp was placed proximal to the LSA, which was snugged, in order to resect the dissection flap that originated within the arch.Case 2 (island patch): 37-year-old male with Marfan syndrome who presented with a type B aortic dissection two years prior, initially managed conservatively until the proximal thoracic diameters began expanding.He was planned for an extent II TAA replacement from the distal to LSA to individual iliacs.Case 3 (end graft): 65-year-old male with degenerative extent IV TAA aneurysm.Planned extent IV TAA replacement from lower to iliac bifurcation.Motor-evoked potential (MEP) signal decreased intraoperatively during opening of the visceral segment and a single large lumbar artery was reimplanted to the main graft using an end graft technique.

Patients undergoing open thoracoabdominal aortic aneurysm repair require large incisions associated with considerable postoperative pain. Cryoanalgesia of intercostal nerves is a plausible strategy to reduce postoperative surgical pain and opioid requirement according to two published case series from North America.1,2 We aim to evaluate the impact of cryoanalgesia on opioid use in the UK.

Aortic dissection during pregnancy is a life-threatening condition for both mother and fetus. We present the case of a 34-year-old woman with a rapidly expanding abdominal aorta in the context of a chronic type B aortic dissection. A 4 to 6 weeks' viable pregnancy was incidentally diagnosed during the preoperative workup. She underwent urgent extent II thoracoabdominal aortic aneurysm repair with left-sided heart bypass. Postoperatively, vaginal ultrasound evaluation confirmed viability of the fetus, but the patient wished to terminate the pregnancy because of the possible unknown hypoxic effects on the fetus.

Acute type-A aortic dissection is a rare but life-threatening cardiac surgery emergency. Immediate operative management is important to give patients the best chance of survival. However, where an aortic dissection is complicated by a concurrent hemorrhagic stroke the risks of precipitating a catastrophic intracranial hemorrhage during surgery must be balanced against the risk of aortic rupture. The optimal timing of surgery in this rare presentation of type-A aortic dissection is unknown. In this case report we describe a 67-year-old gentleman who initially presented with neurological symptoms, and was diagnosed with an acute intracerebral hemorrhage, but was subsequently also diagnosed with an acute type-A aortic dissection. He proceeded to have a successful tissue aortic root replacement, total arch replacement with zone two frozen elephant trunk implantation 4 weeks after his initial diagnosis.

Background: Patients with major aortic pathology have complex needs, require lifelong surveillance and often multiple interventions. Multidisciplinary teams (MDT) have been shown to improve care in other specialities but there are no such reports related to dedicated Aortovascular MDTs. We aim to review our experience and decision making of an Aortovascular MDT over 5 years period since its beginning. Methods: Cohort retrospective analysis of prospectively collected data for all patients referred to our Aortovascular MDT since its inception. Demographics, diagnosis and outcome of discussions were analysed. Results: From April 2015 to April 2020, 871 discussions took place at the MDT meeting on 649 unique patients. Mean age was 52 [17-84] years, 414 (64%) were male, 209 (32%) had previous cardiac surgery and 85 (13%) had connective tissue disorder. Final decision from the MDT meeting was surgery (220, 33.9%), surveillance (240, 36.9%), not for intervention (42, 6.5%), further investigation (53, 8.2%), assess for surgery (30, 4.6%), endovascular therapy (28, 4.3%), other (36, 5.5%). Of 649 patients discussed, 591 (91%) underwent the management suggested by the meeting. Of the 58 (9%) that were not carried out, the most common reason was patient preference. Conclusions: Patients with major aortic pathology should expect care from a dedicated MDT, not only to benefit from the optimal choice of therapy but also the holistic care delivered by a team with expertise in all aspects of care for complex Aortovascular pathologies. We believe Aortovascular MDTs should become a standard of care in such patients.

Retrograde type A aortic dissections (RTAAD) are less frequent than the antegrade type A form, where the primary entry tear is located within the root, ascending and/or arch of the aorta and the dissection propagates antegradely into the distal aorta. Retrograde type A aortic dissection (RTAAD) can be spontaneous or secondary to the instrumentation of the descending and thoraco-abdominal aorta. It has anatomical differences compared to antegrade type A aortic dissection that impact the management and prognosis. Treatment is not standardized. We report our approach to spontaneous RTAAD in our institution between 2018 and 2022 (n = 15). The mean age was 60.1 years and 93% were male. Aortic valve, coronary arteries and supra-aortic trunks were spared by the dissection in 80% of the cases; distal extension to iliacs was common and lower limb malperfusion was present in 4 cases (27%). The ascending aorta was dilated at presentation in 60% of the cases. Emergency surgery with arch/FET replacement was offered to 11 patients (73%); 3 patients (20%) received a limited proximal aortic repair; 1 patient was treated conservatively. Overall mortality was 47% (100% for limited proximal repair and 22% for those who received arch/FET). We advocate for aggressive treatment of RTAAD excluding the primary entry tear to prevent immediate- and mid-term complications.