Background The Nexus Duo endograft is a novel device designed for endovascular repair of aneurysmal disease of the aortic arch (EAAR). It features a dedicated indwelling branch for the brachiocephalic trunk and a customized retrograde branch for either the left common carotid artery (LCCA) or left subclavian artery (LSA). This study evaluates the early clinical outcomes of the Nexus Duo endograft in EAAR. Methods This multicenter, observational, physician-sponsored registry retrospectively analyzed prospectively collected data from nine European centers. All consecutive patients who underwent EAAR with the Nexus Duo endograft between January 2023 and April 2025 were included in the study. The primary end point was 30-day mortality. Secondary end points included technical success, overall reinterventions, major adverse events (MAEs), and the incidence of endoleaks at 30 days. Results Thirty patients (53% female) were treated. Indications for EAAR included nondissecting aneurysm (n = 7, 23.3%), post type-B-dissection aneurysm (n = 7, 23.3%), post type-A-dissection aneurysm (n = 14, 46.7%), false aneurysm (n = 1, 3.3%), and penetrating ulcer (n = 1, 3.3%). The LSA was the target vessel in 17 patients (56.7%). Seventeen patients underwent simultaneous LCCA-LSA bypass (58.6% using polytetrafluoroethylene grafts). Technical success was 100%. At 30 days, the mortality rate was 3.3% (n = 1), the reintervention rate was 16.7%, and the MAE rate was 6.7%. No disabling strokes were observed. One transient ischemic attack occurred and one type Ia endoleak (3.3%) were observed at 30 days. Conclusions In this real-world, multicentre study, the Nexus Duo endograft demonstrated a favorable early safety profile, with high technical success, no disabling strokes, and encouraging 30-day outcomes.

OBJECTIVES:This study investigates differences in short- and mid-term outcomes in patients without malperfusion undergoing surgery for acute type A aortic dissection between specialized aortic surgeons and non-aortic surgeons. METHODS:Patients who underwent surgery for acute type A aortic dissection between 2013 and 2023 defined as M0 (no malperfusion) according to the type-entry-malperfusion classification were included and divided into 2 groups according to the surgeon's expertise: aortic surgeon vs non-aortic surgeon group, whereas an aortic surgeon was defined by expertise in extensive aortic arch surgery including frozen elephant trunk implantation on a regular basis (average ≥5/year). After propensity score matching, the groups were compared in terms of intraoperative variables and outcomes including a primary combined end-point consisting of 30-day mortality and/or CT-confirmed stroke. RESULTS:The matched cohort comprised 2 balanced groups with 234 patients (117 in each group). Cardiopulmonary bypass, cross-clamp and distal arrest times did not differ significantly between the groups. However, more extensive aortic surgery was performed by aortic surgeons: aortic root replacement (Bentall) (P = .007; odds ratio [OR] 1.18 [CI, 1.05-1.32]), valve-sparing root replacement (David) (P = .013; OR 1.05 [CI, 1.01-1.10]), and frozen elephant trunk implantation (P < .001; OR 1.18 (CI, 1.09-1.27]). The combined end-point of 30-day mortality and/or CT-confirmed stroke was 26% in the non-aortic surgeon vs 23% in the aortic surgeon group (P = .54; OR 0.97 [CI, 0.86-1.08]). Further clinical outcomes, including 5-year survival, did not differ significantly (P = .170). CONCLUSIONS:Patients without preoperative malperfusion undergoing surgery for ATAAD show no differences in terms of short- and mid-term outcomes between specialized aortic and non-aortic surgeons. However, more extensive aortic repair may be performed safely by specialized aortic surgeons. These results support the definition of an aortic surgeon based on experience with the frozen elephant trunk technique and may advocate for call coverage by an aortic surgeon for type A repair at high-volume centres.

Background Endovascular aortic repair (EVAR) is the gold standard for abdominal aortic aneurysm, but complex anatomy may require individualized strategies. Case Summary We report a 72-year-old multimorbid man with a left ventricular assist device and stage 3 chronic kidney disease, presenting with abdominal aortic aneurysm (up to 7.7 cm), residual type B dissection with unfavorable remodeling, and the left renal artery originating from the false lumen. An interdisciplinary approach consisted of a laparoscopic nephrectomy with ex vivo preservation, followed by EVAR and renal autotransplantation into the right iliac fossa. Postoperative recovery was uneventful, with stable renal function and satisfactory imaging showing exclusion of the entry tear. Discussion Standard EVAR would have compromised perfusion of the left kidney. More complex endovascular strategies, including branched or fenestrated repair, were technically prohibitive. Take-Home Message Renal autotransplantation may serve as a viable bailout strategy enabling EVAR in highly selected patients requiring organ preservation.

Acute type A aortic dissection (ATAAD) is a life-threatening emergency requiring urgent surgery. Advanced age is a major risk factor for operative mortality and strongly influences treatment decisions. This systematic review evaluates perioperative characteristics, surgical strategies in regard to outcomes and mortality in patients older than 70 years undergoing ATAAD repair. A PRISMA-guided database search identified original studies published between 2000 and 2025. Early and late outcomes were pooled, with thirty-day mortality as the primary endpoint and postoperative complications, organ dysfunction and quality of life as secondary endpoints. Key aspects of ATAAD management, including patient selection, extent of repair, cerebral protection and perioperative organ protection strategies, were systematically analyzed. Of 1,910 screened studies, 41 publications including 3,969 elderly patients were analyzed, encompassing randomized, observational and case-control designs. Preoperative malperfusion occurred in 22.8% of patients, most commonly cerebral (16.7%) and renal (13.5%). When analyzed within their respective cohorts, the majority of patients received standard of care ascending aorta or hemiarch replacement. This was followed by total arch replacement and root replacement. Mean cardiopulmonary bypass, cross-clamp and circulatory arrest times were 201, 104 and 45 min, respectively, at 23 °C. Postoperative morbidity was substantial, with neurological complications (12%), delirium (30%), respiratory failure (21%) and dialysis-dependent renal failure (22%). 30-day mortality was in average 21% and was mainly due to bleeding, low cardiac output and multiple organ failure. Long-term quality of life, assessed by SF-36, remained satisfactory. However, data was overall heterogeneously presented and therefor limited interpretability concerning the addressed endpoints. ATAAD surgery in elderly patients remains challenging due to frailty and comorbidities. Careful patient selection and treatment in specialized centers are essential. Despite the emerging hybrid and endovascular approaches, open repair was the most commonly reported intervention. The available data suggests that advanced age was not consistently associated with withholding surgical treatment, especially in cases of absence of malperfusion

Objective: To investigate differences in neurologic outcomes between unilateral and bilateral antegrade cerebral perfusion during prolonged circulatory arrest in surgery for acute type A aortic dissection (ATAAD). Methods: Patients who underwent surgery for ATAAD between 2013 and 2023 receiving either unilateral antegrade cerebral perfusion (uACP) or bilateral antegrade cerebral perfusion (bACP) during prolonged caudal circulatory arrest (≥30 minutes) were included in the primary study cohort. Preoperative computed tomography scans were analyzed in terms of Type-Entry-Malperfusion classification and supra-aortic dissection patterns. After propensity score matching, the groups were compared in terms of clinical outcomes, including new postoperative strokes. Results: A total of 382 patients (206 uACP and 176 bACP) were included. The matched cohort comprised 2 balanced groups with 170 patients (85 in each group). The median circulatory arrest time was 44 (interquartile range [IQR], 36-57) minutes in the uACP group and 44 (IQR, 40-56) minutes in the bACP group (P = .87). Thirty-day mortality occurred in 15 patients (18%) in each group (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.89-1.12; P = 1.00). New postoperative stroke was detected in 6 uACP patients (7%) and in 4 bACP patients (5%) (OR, 0.98; 95% CI, 0.91-1.05; P = .52). Postoperative delirium occurred in 30 uACP patients (35%) and in 35 bACP patients (41%) (OR, 1.06; 95% CI, 0.92-1.23; P = .43). Conclusions: Both uACP and bACP are adequate cerebral perfusion strategies during circulatory arrest exceeding 30 minutes in surgery for ATAAD. Additional intraoperative and anatomic factors may be considered to determine the optimal selective cerebral perfusion strategy.

OBJECTIVES:This study investigates early and midterm outcomes after surgery for acute DeBakey type I dissection between classic hemiarch replacement and additional open noncovered stenting of the aortic arch. METHODS:Patients who underwent surgery for acute DeBakey type I dissection receiving solely hemiarch replacement (2015-2022) or additional open noncovered stenting of the aortic arch (2018-2022) using the 'Ascyrus Medical Dissection Stent' (AMDS) were included. After propensity score matching, the groups were compared in terms of clinical and radiological outcomes. RESULTS:A total of 261 patients (155 hemiarch, 106 AMDS) were included. After matching, the cohort comprised 2 balanced groups with 108 patients (54 each group): 30-day mortality was 19% in the hemiarch group versus 15% in the AMDS group [P = 0.61, odds ratio (OR) = 0.77 (confidence interval (CI) 0.27-2.12)]. New postoperative stroke [P = 0.99, OR = 0.98 (CI 0.11-8.43)] and revision for malperfusion did not differ [P = 0.38, OR = 1.70 (CI 0.53-5.99)]. The incidence of new distal anastomotic entries was significantly lower in the AMDS group with 17% vs 45% in the hemiarch group [P = 0.028, OR = 0.35 (CI 0.13-0.87)]. True lumen expansion was significantly improved in the aortic arch [P = 0.006, OR = 3.15 (CI 1.41-7.34)] and stented portion of the descending aorta [P < 0.001, OR = 8.51 (CI 3.65-21.24)] as well as false lumen thrombosis in the aortic arch [P = 0.048, OR = 2.24 (CI 1.02-5.07)]. Two-year survival did not differ (P = 0.170). CONCLUSIONS:Additional AMDS implantation shows similar clinical outcomes, reduces the risk for new distal anastomotic entries and may be associated with superior positive aortic remodelling in the aortic arch and stented portion of the descending aorta. Long-term results regarding aortic remodelling and reintervention rate are highly needed.

BACKGROUND:Acute myocardial infarction with cardiogenic shock often requires urgent mechanical circulatory support (MCS) and, if recovery fails, definitive replacement therapy. We report the complex management of a 49-year-old man who developed an iatrogenic type A aortic dissection (iTAAD) after failed percutaneous coronary intervention. CASE SUMMARY:Initial stabilization with an Impella device was complicated by vascular injury and hemodynamic instability, requiring escalation to advanced MCS. As the iTAAD remained stable without systemic malperfusion, conservative management was chosen. Persistent severe left ventricular dysfunction prevented recovery, leading to implantation of a durable left ventricular assist device. DISCUSSION:Unlike spontaneous dissections, iTAADs arise from focal procedural injury, and-without malperfusion-may be safely managed conservatively, although no formal guidelines exist. TAKE-HOME MESSAGE:In selected patients with stable iTAAD and cardiogenic shock due to concomitant myocardial infarction, a "watchful waiting" strategy combined with MCS can safely bridge to durable left ventricular assist device implantation.

OBJECTIVES:The aim of this study was to evaluate the outcomes of transposition of the omentum into the mediastinum to support the replacement of infected aortic grafts or to cover infected aortic grafts that are not amenable for surgical replacement. METHODS:All patients with thoracic aortic graft infections who underwent mediastinal transposition of the omentum at our institution between 2005 and 2023 were included in this study. Mediastinal transposition of the omentum was performed either after replacement of the infected graft ('curative concept') or solely as bailout procedure by wrapping the infected graft ('palliative concept'). The diagnosis, including computed tomography scans during follow-up, was made according to the criteria of the Management of Aortic Graft Infection Collaboration. RESULTS:The patient cohort consisted of 31 patients. Both in-hospital and 1-year mortality were 0% (n = 0) for the curative concept (n = 9) compared to 23% (n = 5) and 41% (n = 9) for the palliative concept (n = 22), respectively. There was no graft infection-associated death or recurrence of infection after 3 years in the curative group. Survival was 52% at 3 years in the palliative group, with freedom of infection in 59% of the patients (n = 13). CONCLUSIONS:Transposition of the omentum and wrapping of the infected aortic prosthetic graft is a useful bailout strategy for patients who are ineligible for replacement of an infected aortic graft. However, mortality stays high. For radical treatment of aortic graft infections, it may prove an effective supportive therapy and represents an important tool in the armamentarium of cardiac surgeons.

The treatment of DeBakey type I aortic dissection remains a major challenge in the field of aortic surgery. To upgrade the standard of care hemiarch replacement, a novel device called an “Ascyrus Medical Dissection Stent” (AMDS) is now available. This hybrid device composed of a proximal polytetrafluoroethylene cuff and a distal non-covered nitinol stent is inserted into the aortic arch and the descending thoracic aorta during hypothermic circulatory arrest in addition to hemiarch replacement. Due to its specific design, it may result in a reduced risk for distal anastomotic new entries, the effective restoration of branch vessel malperfusion and positive aortic remodeling. In this narrative review, we provide an overview about the indications and the technical use of the AMDS. Additionally, we summarize the current available literature and discuss potential pitfalls in the application of the AMDS regarding device failure and aortic re-intervention.

Background: Prosthetic graft infection of the ascending aorta and aortic arch requires in situ reconstruction due to close location to the heart. Transposition of the greater omentum into the mediastinum and coverage of the new graft with the omentum is an additional measure to protect the suture line from reinfection by enhancing microbiological resistance. In high-risk patients it may be a solely surgical treatment as a palliative therapy by wrapping the old, infected prosthetic graft. This surgical procedure is barely performed for the treatment of infected aortic graft prostheses.

Background: Perioperative stroke remains a devastating complication in the operative treatment of acute type A aortic dissection. To reduce the risk of perioperative stroke, different perfusion techniques can be applied. A consensus on the preferred cerebral protection strategy does not exist. Methods: To provide an overview about the different cerebral protection strategies, literature research on Medline/PubMed was performed. All available original articles reporting on cerebral protection in surgery for acute type A aortic dissection and neurologic outcomes since 2010 were included. Results: Antegrade and retrograde cerebral perfusion may provide similar neurological outcomes while outperforming deep hypothermic circulatory arrest. The choice of arterial cannulation site and chosen level of hypothermia are influencing factors for perioperative stroke. Conclusions: Deep hypothermic circulatory arrest is not recommended as the sole cerebral protection technique. Antegrade and retrograde cerebral perfusion are today’s standard to provide cerebral protection during aortic surgery. Bilateral antegrade cerebral perfusion potentially leads to superior outcomes during prolonged circulatory arrest times between 30 and 50 min. Arterial cannulation sites with antegrade perfusion (axillary, central or carotid artery) in combination with moderate hypothermia seem to be advantageous. Every concept should be complemented by adequate intraoperative neuromonitoring.

Background Thoracic endovascular aortic repair (TEVAR) is a well-established therapy for descending aortic aneurysms (DTA). There is a paucity of large series reporting the mid- and long-term outcomes from this era. The main aim of this study was to evaluate the outcomes of TEVAR with regards to the effect of aortic morphology and procedure-related variables on survival, reintervention and freedom from endoleaks. Methods In this retrospective single center study, we evaluated the clinical outcomes among 158 consecutive patients with DTA than underwent TEVAR between 2006 and 2019 at our center. The cohort included 51% patients with device landing zones proximal to the subclavian artery and 25.9% patients undergoing an emergent or urgent TEVAR. The primary outcome was survival, and secondary outcomes were reintervention and occurrence of endoleaks. Results Median follow-up was 33 months [IQR 12 to 70] while 50 patients (30.6%) had longer than 5-year follow-up. With a median patient age of 74 years, post-operative Kaplan Meyer survival estimates were 94.3% (95%CI 90.8–98.0, SE 0.018%) at 30 days, 76.4% (95%CI 70.0–83.3, SE 0.034%) at one year and, 52.9% (95%CI 45.0–62.2, SE 0.043%) at five years. Freedom from reintervention at 30 days, one year, and five years was 92.9% (95%CI 89.0–97.1, SE 0.021%), 80.0% (95%CI 72.6–88.1, SE 0.039%), and 52.8% (95%CI 41.4–67.4, SE 0.065%), respectively. On cox regression analysis greater aneurysm diameter, and the use of device landing zones in aortic regions 0–1 were associated with an increased probability of all-cause mortality, and with reintervention during follow-up. Independent of aneurysm size undergoing urgent or emergent TEVAR was associated with higher mortality risk for the first three years post-operative but not on long-term follow-up. Conclusions Larger aneurysms and those requiring stent-graft landing in aortic zones 0 or 1, are associated with higher risk for mortality and reintervention. There remains a need to optimize clinical management and device design for larger proximal aneurysms.

IntroductionOpen surgical repair remains the current gold standard for the treatment of acute type A aortic dissection. However, especially elderly patients with relevant comorbidities who are deemed unfit for open surgery may benefit from a minimally invasive endovascular approach.MethodsWe report a case of an 80-year-old male with retrograde acute type A aortic dissection and peripheral malperfusion after receiving thoracic endovascular aortic repair due to thoracic aortic aneurysm. Our individualized endovascular approach consisted of left carotid-subclavian bypass, proximal extension of thoracic endovascular aortic repair using a covered stent graft and a single covered stent graft for the ascending aorta in combination with an uncovered stent for the aortic arch.ResultsPostoperative computed tomographic angiography demonstrated excellent outcome with no signs of endoleak or patent false lumen. Follow-up after 3.5 years showed a stable result with no signs of stent failure or dissection progress. No aortic re-interventions were needed in the further course.DiscussionAn individualized endovascular approach may be justified for acute type A aortic dissection in elderly patients with high surgical risk if performed in specialized aortic centers. Additional short-length stent graft devices are needed to address the anatomical challenges of the ascending aorta. For enhanced remodeling of the dissected aorta, the use of an additional uncovered stent may be advisable.

OBJECTIVES:The aim of this study is to investigate the outcome of elderly patients with surgically treated acute type A aortic dissection (ATAAD) complicated by malperfusion. METHODS:Patients ≥70 years old who underwent surgical treatment for ATAAD between January 2000 and December 2020 were enrolled in this study and stratified by their specific Penn Classification into 4 different subgroups, where Penn Abc was defined as multilevel malperfusion. Short- and long-term outcomes were investigated. Multivariable binary logistic regression was performed to identify risk factors for 1-year mortality. RESULTS:Four hundred elderly patients underwent surgical treatment for ATAAD. A total of 204 (51%) patients had no evidence of malperfusion (Penn Aa), 106 (26.5%) had localized organic malperfusion (Penn Ab), 44 (11%) patients had systemic malperfusion (Penn Ac) and 46 (11.5%) suffered from multilevel malperfusion (Penn Abc). For the latter, in-hospital mortality was 70% (P < 0.001). Age (P < 0.006) and multilevel malperfusion (P < 0.001) were independent risk factors for 1-year mortality. Patients with multilevel malperfusion showed the worst 1-year survival (P < 0.001). In the case of Penn Aa, in-hospital mortality was 13% (P < 0.001). CONCLUSIONS:Surgery may lead to satisfactory results in the absence of malperfusion, even in octogenarians. Elderly patients with multilevel malperfusion show very poor surgical outcome. In these patients, the decision for surgery should be taken with caution. Operation, if performed, should be carried out by experienced teams only.

OBJECTIVES: The goal of this study was to describe the factors affecting mid and late aortic remodelling following thoracic endovascular aortic repair with the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique among patients with complicated acute or subacute type B aortic dissection. METHODS: A retrospective single-centre study that evaluates clinical and morphological outcomes among 65 consecutive patients. The area and diameter of the true and false lumen, overall aortic diameter and false lumen perfusion were evaluated. RESULTS: Concomitant direct visceral artery stenting was successfully conducted in 32 (49%) patients. There was one (1.5%) postoperative stroke; three (4.6%) patients developed spinal cord ischaemia; two (3%) patients suffered retrograde type A dissection; and two (3%) patients had mesenteric ischaemia, despite successful reperfusion, that required a bowel resection. Median postoperative follow-up was 63.1 (interquartile range, 32.1- 91.8) months. The probability of survival was 96.9% [95% confidence interval (CI) 88.3%-99.2%] at 30 days, 93.9% (95% CI 84.4%-97.6%) at 1 year, 78.0 (95% CI 64.2%-87.0%) at 5 years and 72.8% (95% CI at 57.9%-83.2%) at 10 years postoperatively. There was a statistically significant postoperative increase in true-lumen area, diameter and true-lumen index in all five aortic levels measured. Complete false lumen (FL) thrombosis at the coeliac trunk, renal arteries and aortic bifurcation levels was observed in 47%, 15% and 24% of patients at midterm (6-15 months) and in 29%, 21% and 29% on late (later than 21 months) computed tomography angiograms (CTA). Persistent false lumen (FL) perfusion at the coeliac level on midterm CTA was associated with a larger extent of late aortic growth (P = 0.042) and was, in the majority of cases, caused by iliac re-entries either alone (28.57) or in combination with visceral and lumbar (28.57%) or distal aortic (10.71%) re-entries. A larger abdominal aortic diameter at midterm was associated with an increased probability of distal aortic reinterventions (hazard ratio 7.26, 95% CI 2.41-21.9, P < 0.001). CONCLUSIONS: Persistent FL perfusion of the distal aorta at midterm following TEVAR with the PETTICOAT technique among patients with acute and subacute type B dissection is caused mainly by iliac, visceral, lumber and distal aorta re-entries. Patients with persistent FL perfusion have an increased risk of aortic aneurysmal growth at late follow-up.

Background: Thoracic endovascular repair (TEVAR) for descending thoracic aneurysms (DTA) with proximal device landing zones (DLZ) in the aortic arch sets additional challenges. The aim of this study was to evaluate outcomes among these patients.