BackgroundSecuring hemostasis at graft-to-aorta anastomoses represents a challenging feature of the surgical management of aortic pathologies, and can impact postoperative morbidity and mortality. A new refined suturing technique was developed to address this challenge.MethodsA Dacron tube graft of appropriate size is secured within the aortic lumen using a horizontal 4-0 Prolene U-stay suture, and its two arms are used to complete the anastomosis continuously. With every bite, the needle is driven horizontally across an outer circumferential felt strip and aorta (out-in), through the graft at a 2-3-mm distance from its edge (out-in), back through the graft at a 7-8-mm distance from its edge (in-out), and finally bridging over the aortic edge back to its outer aspect without piercing the aortic wall. The two running sutures are firmly tightened and knotted, and Bioglue is applied.ResultsThe described technique was used in 175 patients who underwent ascending aortic replacement for aortic aneurysm or acute dissection. We have found its application to be associated with improved hemostasis and reduced intraoperative and postoperative blood loss. Additional sutures were rarely needed for hemostasis at suture lines, and there were no incidents of false aneurysm formation at anastomosis lines on long-term follow-up.ConclusionsThe described technique is associated with improved hemostasis, reduced blood loss, and decreased operating time, ultimately bringing significant benefits to patients undergoing surgical management of aortic pathologies.

Surgical patch angioplasty is an alternative to classic coronary artery bypass grafting for patients with isolated coronary ostial stenosis and normal distal coronary arteries. We present a case where we successfully used an arterial patch from the right internal mammary artery to restore patency of an isolated ostial left main coronary artery stenosis. This technique is likely to offer more physiological antegrade myocardial perfusion, mimic normal vascular anatomy, and may be associated with an improved outcome.

Chronic kidney disease increases risk of cardiac complications. Concurrent aortic dissection and infective endocarditis is exceptionally rare. A 29-year-old male with hypertension and chronic kidney disease post-renal transplant presented with chest and back pain. Imaging revealed acute Stanford Type A aortic dissection. Emergency surgery also uncovered undiagnosed infective endocarditis. The patient underwent aortic root replacement and was treated with intravenous antibiotics for 6 weeks postoperatively. He had an uneventful recovery without cardiac or infective complications. Physicians should maintain a high index of suspicion for concurrent cardiac complications in symptomatic chronic kidney disease patients, as prompt diagnosis and treatment is crucial for good outcomes in these rare cases.

A 48-year-old female underwent emergency surgery for an undetermined mass in the right atrium associated with bilateral pulmonary artery emboli. Under deep hypothermic circulatory arrest, a large gelatinous mass was excised from the right atrium, and large embolic lumps were removed from both main pulmonary arteries. Histopathological testing of excised specimens confirmed the diagnosis of a vascularized myxoma. At 6 months of follow-up, repeated transthoracic echocardiography has not shown any signs of local recurrence or elevated pulmonary artery pressure. The potential for right atrial myxoma as a source of pulmonary embolization should be borne in mind, as this potentially fatal yet curable condition demands emergency surgical intervention.

The European Society of Cardiology (ESC) develops clinical practice guidelines for a number of cardiovascular diseases including heart failure (HF) to provide evidence-based, up-to-date recommendations designed to be applicable in daily practice.1, 2 These guidelines serve as a vital tool for healthcare professionals, offering guidance on patient management based on clinically reviewed contemporary evidence. However, observational studies highlight a gap and geographic variations in the implementation of guideline recommendations,3, 4 resulting in missed opportunities to reduce morbidity, mortality, and healthcare utilization associated with HF.5 The implementation of clinical practice guidelines in clinical practice is a complex and challenging process influenced by multiple factors. Numerous barriers and enablers have been identified.6 First, barriers related to the guidelines themselves include their complexity, limited accessibility, and poor applicability to real-world practice. Second, barriers associated with healthcare providers include a lack of knowledge and skills, as well as language barriers in multi-ethnic countries. Additionally, patient-related factors, such as limited awareness, poor adherence, and financial constraints, play a significant role. Finally, institutional and resource-related challenges, such as time constraints, suboptimal healthcare networks, inadequate interprofessional communication pathways, and insufficient incentives or reimbursement, further complicate effective implementation. In many low- and middle-income countries (LMICs), which account for approximately 50% of global cardiovascular mortality,7 the magnitude of the 'evidence–practice' gap in HF care is less appreciated and likely more substantial compared with developed countries (Figure 1). Many developing countries lack a structured approach for HF care, with missed or delayed follow-up and limited access to HF specialists and advanced HF therapies.8, 9 Understanding the healthcare systems and challenges in these regions is therefore critical. Unfortunately, research from LMICs remains sparse. For example, between 2008 and 2017, 80% of cardiovascular publications originated from high-income countries, while only 0.2% came from LMICs. Syria, for instance, contributed approximately 5% of all publications from LMICs, which equates to just 10 cardiovascular disease publications over a decade.7, 10 The Syrian crisis had a profound impact on the Syrian healthcare system, resulting in the undertreatment of many cardiovascular conditions, including HF.8, 11 During the war years, Syria's healthcare infrastructure suffered extensive damage, leading to severe shortages of medical equipment, pharmacotherapies, and skilled healthcare professionals who are capable of performing complex and advanced procedures.8, 12 According to the Syrian Archive, more than 445 attacks on hospitals by the Syrian regime were documented, with the economic cost of the crisis exceeding 1 trillion euros. In 2022, a survey was conducted in Syria to assess the implementation of recommended care processes for HF patients.8 The findings revealed that the ongoing economic crisis has placed an enormous strain on the Syrian healthcare system and patients alike, with over 70% of patients unable to access necessary treatments due to financial barriers, lack of local availability, and limited medical expertise. The survey showed that more than 50% of HF patients do not receive optimal guideline-directed medical therapy (GDMT), and over 90% are unable to access advanced device-based treatments due to their prohibitive costs. Furthermore, the absence of local expertise in performing cardiac resynchronization therapy (CRT) procedures adds another significant challenge to providing comprehensive care for HF patients in Syria (Figure 1). According to the main and only local official companies providing devices in Syria over the last 10 years, fewer than five CRT devices were implanted in the entire country in both 2023 and 2024. This means that less than 1% of HF patients eligible for CRT received it. Preventive measures for HF are also lacking in Syria, with poor optimization to long-term illnesses, such as diabetes, hypertension, and chronic kidney disease. Surprisingly, to this day, the major hospitals in Syria lack facilities for primary percutaneous coronary intervention (PCI), and all acute myocardial infarction patients receive fibrinolysis instead. Primary PCI is only available in private settings. This is one of the most significant factors contributing to the development of HF. Many individual approaches have been undertaken to address these gaps.11, 12 First, to share knowledge and raise awareness of comprehensive HF care across Syria, numerous educational meetings were organized in different cities. These efforts were led by physicians living abroad in collaboration with local physicians. Additionally, social media has been utilized as a vital platform to disseminate initiatives effectively. Tailored approaches were also explored to adapt guideline recommendations to the Syrian financial and healthcare circumstances. For example, left bundle branch pacing (LBBP), which utilizes the traditional two-chamber pacing system, but with the ventricular electrode implanted on the left bundle branch, was introduced as a viable and more affordable alternative treatment to biventricular CRT in patients with HF who have an indication for CRT. As part of this initiative, a number of LBBP cases were performed in Damascus through a collaborative effort between Syrian operators based in Germany and local Syrian physicians. The results were highly encouraging, demonstrating comparable outcomes to biventricular CRT while offering a cost-effective solution for patients unable to afford biventricular CRT.12 Whilst the equipoise between LBBP and CRT is still awaiting a strong body of evidence, introducing LBBP in Syria was an extremely important initiative given the lack of availability, accessibility and affordability of CRT. Now, with a renewed sense of motivation following the country's progress toward stability and freedom, we are committed to continuing this work with local physicians and look forward to expand such collaboration to healthcare authorities and decision-makers to build on previous experiences and transform HF care across Syria to another level. Our focus is to initiate a comprehensive programme for HF care in Syria by defining the gaps in the current infrastructure and providing solutions that are both feasible and sustainable, such as the systematic collection of structured clinical data using harmonized definitions, as well as the participation in international clinical registries. Such accomplishments can only be made possible through a dedicated support from international professional bodies such as the ESC and the World Health Organization. Strategies would be defined to spread knowledge among physicians in Syria at all levels, from medical students to cardiology consultants. This would be achieved by conducting educational meetings and workshops with the support of physicians from Europe and around the world. Additionally, efforts would be made to obtain educational grants from international bodies. Secondly, we aim to support hospitals with essential materials to improve patient outcomes, such as GDMT. Furthermore, we plan to establish programmes such as 'Cardiac Devices for Syria' to provide the country with pacemakers, implantable-cardioverter defibrillators, and CRT devices, as these technologies are currently not widely available in Syria. Additionally, we aim to implement a programme called 'PCI for Syria' to provide primary PCI for myocardial infarction at the country's main hospital—an essential step in preventing HF. These goals can be achieved with the support of Western countries and international health organizations. We are grateful to Armin Schweitzer for his technical and graphical help. This work was written under the supervision of the Syrian Cardiovascular Association and the Syrian National Heart Failure Working Group. Open Access funding enabled and organized by Projekt DEAL. Conflict of interest: A.A. reports speaker honoraria from Boston Scientific and Bayer. All other authors have nothing to disclose.

A 51-year-old female underwent emergency mitral valve replacement for mitral stenosis with an undetermined mass which was attached to the anterior mitral leaflet. Histopathological testing of the excised specimen confirmed the diagnosis of rheumatic mitral disease in combination with a primary rhabdomyosarcoma. Postoperative adjuvant chemotherapy with pazopanib hydrochloride was given. At 10 months of follow-up, repeated computed tomographic screening has not shown any signs of local recurrence or secondary metastases. The potential for the existence of primary rhabdomyosarcomas should be borne in mind when faced with undetermined masses on mitral leaflets, even in the presence of rheumatic disease.

Background. Surgical mobilization of the internal mammary artery (IMA) can induce graft vasospasm, which is commonly managed by wrapping the IMA in a vasodilator-soaked swab before grafting. However, the choice of the most effective topical vasodilator remains the subject of continued investigation. We carried out a prospective randomized controlled trial to compare the effect of topically applied milrinone, nitroglycerin, and normal saline on IMA free flow. Methods. Forty-six consecutive patients undergoing elective primary coronary artery bypass grafting were enrolled. After the left IMA was harvested, free flow was measured under controlled hemodynamic conditions before any intervention (flow 1) and at a mean of 12.5 minutes after the topical application of one of three agents (milrinone, nitroglycerin, or normal saline) on the IMA (flow 2). Results. All agents induced a significant increase in IMA flow, and flow 2 was significantly higher in the nitroglycerin and milrinone groups compared to the normal saline group, even while controlling for flow 1 as a centered continuous variable. Nevertheless, there was no statistically significant difference in flow 2 between the nitroglycerin and milrinone groups. Conclusions. Topically applied milrinone and nitroglycerin can increase blood flow of the IMA significantly in the early period after surgical mobilization. IMA blood flow was greater after the topical application of milrinone compared to nitroglycerin, but this has failed to reach statistical significance in the present study setting. This trial is registered with NCT06301880.

Objective: This study explored how the Syrian crisis, training conditions, and relocation influenced the National Medical Examination (NME) scores of final-year medical students. Methods: Results of the NME were used to denote the performance of final-year medical students between 2014 and 2021. The NME is a mandatory standardised test that measures the knowledge and competence of students in various clinical subjects. We categorised the data into two periods: period-I (2014-2018) and period-II (2019-2021). Period-I represents students who trained under hostile circumstances, which refer to the devastating effects of a decade-long Syrian crisis. Period-II represents post-hostilities phase, which is marked by a deepening economic crisis. Results: Collected data included test scores for a total of 18 312 final-year medical students from nine medical schools (from six public and three private universities). NME scores improved significantly in period-II compared with period-I tests (p < 0.0001). Campus location or relocation during the crisis affected the results significantly, with higher scores from students of medical schools located in lower-risk regions compared with those from medical schools located in high-risk regions (p < 0.0001), both during and in the post-hostilities phases. Also, students of medical schools re-located to lesser-risk regions scored significantly less than those of medical schools located in high-risk regions (p < 0.0001), but their scores remained inferior to that of students of medical schools that were originally located in lower-risk regions (p < 0.0001). Conclusion: Academic performance of final year medical students can be adversely affected by crises and conflicts, with a clear tendency to recovery upon crises resolution. The study underscores the importance of maintaining and safeguarding the infrastructure of educational institutions, especially during times of crisis. Governments and educational authorities should prioritise resource allocation to ensure that medical schools have access to essential services, learning resources, and teaching personnel.

Objective The presence of a significant left subclavian artery stenosis may occasionally lead to blood flow reversal through a LIMA-to-coronary artery bypass graft during left arm exertion; with "stealing" of myocardial blood supply. The aim of this study was to review our experience with carotid-subclavian bypass in patients with post-CABG coronary-subclavian steal syndrome. Methods This is a retrospective review of all patients who underwent carotid-subclavian bypass grafting for post-CABG coronary-subclavian steal syndrome at Mainz University Hospital between 2006 and 2015. Cases were identified in our institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records. Results Nine patients (all males, mean age of 69.1 years) underwent surgical treatment for post-CABG coronary-subclavian steal syndrome. Medium interval between original CABG and carotid-subclavian bypass grafting was 86.1 months. There were no perioperative deaths, strokes or myocardial infarctions. At a mean follow-up period of 79.9 months, all patients remained asymptomatic and all carotid-subclavian bypass grafts remained patent. One patient required stenting of a common carotid artery stenosis proximal to the graft anastomosis site, and coronary artery stenting was required in four patients in regions other than those supplied by the patent LIMA graft. Conclusion Carotid-subclavian bypass surgery is a safe treatment option even in patients with multivessel disease and severe comorbidities and should be taken into consideration in patients who are deemed fit for surgery and those who would benefit from the excellent long-term patency rates.

Objective: Calafiore and modified del Nido cardioplegic solutions are currently being used during coronary artery bypass surgery. This study aims to compare myocardial ischemic stress associated with both solutions by studying the changes in cardiac metabolites during cardioplegic ischemic arrest and early reperfusion.Methods: Biopsy specimens were taken from the left ventricles of 20 patients undergoing routine coronary artery bypass grafting using Calafiore or modified del Nido cardioplegic solutions. Biopsies were taken immediately after the beginning of extracorporeal circulation (basal biopsy), 30 min after application of the aortic cross-clamp (ischemic biopsy), and 20 min following the removal of aortic cross-clamp (reperfusion biopsy) and were analyzed for their amino acid and lactic acid contents using amino acid analyzer and appropriate kits. Peripheral blood samples were also collected for the determination of blood concentrations of cardiac proteins (CK-MB and troponin I) using an immunofluorescence scanner.Results: Both CK-MB and troponin I increased significantly 12 h postoperatively and were associated with an increase in myocardial lactic acid, but there were no significant differences in markers of myocardial injury between the two groups. Comparison of amino acid concentrations between the two groups according to sampling time showed that glutamic acid concentrations were significantly lower in the Calafiore cardioplegia group compared to the del Nido cardioplegia group, but there were no other significant differences in markers of metabolic stress (taurine and alanine/glutamate ratio) between the two groups. Moreover, there were no significant differences in changes in amino acid concentrations regardless of the type of cardioplegic solution used.Conclusions: Cardioplegic ischemic arrest and early reperfusion are associated with a rise in myocardial metabolic stress. Both Calafiore and modified del Nido cardioplegic solutions are effective in attenuating myocardial substrate derangements and confer equal myocardial protection during routine coronary artery bypass surgery.Trial Registration: ClinicalTrials.gov identifier: NCT06287372

BACKGROUND:Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments. METHODS:A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management. RESULTS:RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001). CONCLUSION:RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Background: Peer-assisted learning has been shown to be constructive in numerous aspects of undergraduate medical education. The purpose of this study was to evaluate the effectiveness of peer-assisted teaching of medical English skills to non-native English-speaking students.Methods: A medical English conversation course was conducted at Damascus University by a group of students. Targeted participants were intermediate level fellow students from the same program. A longitudinal study was carried out between 1st to 31st March 2019 to assess changes in self-assessment of English language skills among course participants. Pre- and post-course appraisal involved a review of previous experience with medical English language, a self-assessment of five English language skills, and an objective measurement of medical English knowledge. In addition, participants were requested to respond to a set of statements related to the importance and the usefulness of peer-assisted teaching of medical English skills. Paired-sample Student t-test was used to compare pre- and post-course appraisal results.Results: 42 students attended the course and completed pre- and post-course appraisals in full. Data analyses showed a statistically significant increase in participants’ confidence in speaking medical English in public (p<0.001) and using English in various medical settings (presenting and discussing cases, writing clinical reports, interviewing patients and reading English medical texts). Objective measurements of medical English knowledge confirmed a significant increase in participants’ knowledge of methods of administration of therapeutics, knowledge of human body parts in English and familiarity with English medical abbreviations. Most participants agreed that peer-education was effective in teaching medical English skills to non-native English-speaking students and in increasing their confidence when using English in real-life medical scenarios.Conclusions:The present study highlights the effectiveness of peer-assisted teaching of medical English skills to non-native English-speaking medical students. Further validation is required and should compare the effectiveness of traditional versus peer-assisted teaching approaches.

On Feb 6, 2023, a seismic event with a magnitude of 7·8 Hz and 7·6 Hz hit both Syria and Turkey, leading to widespread destruction, loss of life, and injuries. The disaster left many individuals without shelter as it devastated buildings and infrastructure. Syria, in particular, was unprepared for such a catastrophe as the country had already been ravaged by a decade-long war.1Kakaje A Al Zohbi R Hosam Aldeen O Makki L Alyousbashi A Alhaffar MBA Mental disorder and PTSD in Syria during wartime: a nationwide crisis.BMC Psychiatry. 2021; 21: 2Crossref Scopus (23) Google Scholar, 2Hamza MK Hicks MH Implementation of mental health services in conflict and post-conflict zones: Lessons from Syria.Avicenna J Med. 2021; 11: 8-14Crossref Google Scholar The psychological trauma caused by the earthquake was likely to impair the mental wellbeing of affected residents. However, psychological support through specialised organisations was only available on a small scale owing to the difficulty of physically reaching the affected population, a shortage of qualified health-care professionals, financial costs, and the social stigma associated with visiting a mental health professional.2Hamza MK Hicks MH Implementation of mental health services in conflict and post-conflict zones: Lessons from Syria.Avicenna J Med. 2021; 11: 8-14Crossref Google Scholar Remotely delivered or digital mental health interventions have not yet been implemented in Syria. In response, a team of psychiatrists, general physicians, and psychotherapists volunteered to launch a free-of-charge virtual psychological clinic, with free access to psychological support services to be delivered in Arabic language, for those affected by the earthquake. This initiative was started by two psychiatrists on February 7, was quickly expanded to eight volunteers by February 12, and finally reached 20 health-care professionals by Feb 20, 2023. Those additional volunteers were only accepted after undergoing a competency-based assessment through interviews with the primary psychiatrists of the team. The primary goal of this service was to enhance access to mental health services for people affected by the earthquake by reducing common barriers and allowing them to choose the treatment and therapist, whether male or female, doctor or counsellor, and the time that suited them best. Our team provided follow-up care and treatment for mental disorders according to The European Network for Traumatic Stress Guideline for psychosocial care following disasters and major incidents.3Juen B Warger R Nindl S et al.The comprehensive guideline on mental health and psychosocial support (MHPSS) in disaster settings. OPSIC, Innsbruck2016Google Scholar Internet and telephone services were provided rapidly to shelters, and affected individuals were able to schedule appointments on a new dedicated mental health platform. Each session was conducted via WhatsApp calls and lasted around 30 min. After receiving extensive feedback, the website was further modified to allow beneficiaries to choose their psychological counsellor, schedule their meeting using emails, and prolong their session to 60 min instead of 40 min. In total, by March 30, 2023, we were able to treat more than 100 people between the ages of 17 and 35 years. Due to the high demand, we tried to give equal opportunities to everyone who made an appointment, and we gave priority to new cases. Our experience shows that when access to areas affected by disasters is limited, immediate psychological support services can be provided online if internet access is available, instead of waiting for the necessary conditions for implementing face-to-face interventions. Our initiative helped individuals of different ages to express their concerns and find a safe space, promote positive behaviour and thinking, and reduce the symptoms of panic attacks, anxiety, depression, insomnia, and post-traumatic stress disorder. For the Obstan mental health platform see https://obstan.org For the Obstan mental health platform see https://obstan.org We declare no competing interests and received no financial support for this letter or its publication.

Acquired perforating dermatoses represent an uncommon group of chronic papulonodular dermatoses of unknown aetiology, characterized clinically by intense itching; and histopathologically by transepidermal elimination of dermal components. Definitive targeted pharmacological approaches are lacking, and the disease is usually refractory to therapy. We report here a case of rapid remission of acquired perforating dermatosis following simple thymectomy. If a role for the thymus in the pathogenesis of acquired perforating dermatoses was to be established, this could pave the way for a yet uncharted surgical therapy for these debilitating conditions.

This report supports the feasibility of pulmonary thromboendarterectomy in thalassemic patients, and highlights the need for a comprehensive evaluation of the cause of pulmonary hypertension prior to determining the likelihood of surgical cure.

Background Prosthetic vascular grafts placed surgically or via endovascular techniques can be subject to the risk of life-threatening graft infections. The Omniflow II vascular prosthesis is a biosynthetic graft that was reported to have favorable properties in resisting infections. Materials and Methods We retrospectively reviewed our 3 years' experience of using the Omniflow II prostheses for aortoiliac reconstructions in patients considered to carry a substantial risk of subsequent prosthetic graft infections (prevention group) as well as in patients with actively infected prosthetic vascular grafts (treatment group). Results Aorto-bi-iliac ( n =4) and aortobifemoral ( n =12) vascular reconstructions were performed using bifurcated Omniflow II prostheses in nine patients in the prevention group and seven patients in the treatment group. During mean follow-up of 28.617.2 months, there was one case of graft infection (6.3%) and graft thrombosis (6.3%) with subsequent successful thrombectomy. Early and late surgical revisions were required in eight (50%) and two (12.6%) patients, respectively. All graft prostheses were patent at last follow-up. Conclusion Using bifurcated Omniflow II vascular prostheses in patients with or at a high risk of vascular graft infection is advisable, and is associated with acceptable reinfection and patency rates.

The efficacy of the superior trans‐septal (STS) approach to the mitral valve has been offset by the perceived risks of adverse postoperative events. The aim of this study was to review our experience with using the left atriotomy (LA) and STS approaches in patients undergoing mitral valve surgery.

Objectives Direct true lumen cannulation (DTLC) of the aorta is an alternative cardiopulmonary bypass cannulation technique in the context of type A acute aortic dissection (A-AAD). DTLC has been reported to be effective in restoring adequate perfusion to jeopardized organs. This study reports and compares operative outcomes with DTLC or alternative cannulation techniques in a large cohort of patients with A-AAD. Methods All patients who underwent surgery for A-AAD between January 2006 and January 2017 in Mainz university hospital were reviewed. The choice of cannulation technique was left to the operating surgeon, however DTLC was our preference in patients who were in state of shock or showed signs of tamponade or hypoperfusion, in cases of potential cerebral malperfusion, as well as in patients who were under resuscitation. Results A total of 528 patients (63% males, mean age 64±13.8 years) underwent emergency surgery for A-AAD. The DTLC technique was used in 52.4% of patients. The DTLC group of patients had worse clinical status at the time of presentation with more shock, tamponade, true lumen collapse, cerebral and other malperfusion states. New neurologic events were diagnosed in around 8% of patients in each group following surgery, but there was a trend for quicker neurological recovery in the DTLC-group. Early mortality rates, short-term and long-term survival rates did not differ between the two groups. Conclusions DTLC is a safe cannulation technique that enables effective antegrade true lumen perfusion in complicated A-AAD scenarios, and is an advantageous addition to the aortic surgeons' armamentarium.

This report highlights the need for close surveillance of bioprosthetic valves. Unaccountable degeneration of bioprosthetic valves can develop early after implantation and usually requires replacing the failed valve with a mechanical prosthesis.

This report highlights the need for distinction between saccular and fusiform aortic aneurysms, considering the high risk of rupture of saccular aneurysms. The management of dissected saccular aneurysms involves elective replacement of the dissected aorta while preserving the aortic valve.