OBJECTIVE: The management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices.
METHODS: In New York, we developed a collaborative group, the New York Aortic Consortium, as a means of cross-linking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature and the integration of endovascular technology into disease management. We summarized the current state of aortic arch surgery in this review article.
RESULTS: Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve haemostasis, simplify future operations or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Among our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and our management strategies of patients with aortic arch disease.
CONCLUSIONS: It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.

UNASSIGNED: The extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair.
UNASSIGNED: Between October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention.
UNASSIGNED: Demographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77).
UNASSIGNED: Emergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.

Background and Objectives: Despite advances in surgical techniques, industry adjuncts, and cerebral perfusion techniques, the in-hospital mortality rate of type A acute dissection (TAAD) remains at 15-30%. This study aimed to investigate the influence of different extents of aortic resection on survival and quality of life (QoL) after long-term follow-up. Materials and Methods: A retrospective observational trial was performed, including 165 patients operated upon for TAAD. Patients were divided into two groups according to the extent of their aortic repair: the first group comprised patients who had ascending aorta replacement and the second included patients who had hemiarch or total arch replacement. The groups were compared with regard to their baseline characteristics, operative characteristics, survival, complications, and QoL during nine years of follow-up. Results: The mean follow-up time was 75.6 months (1-108 months). The mean survival in the ascending aorta repair group was 89.651 (81.242-98.061) months and was 54.801 (40.053-69.548) months in the hemiarch and arch group; the difference between the groups was significant (log-rank p < 0.001). The rate of new postoperative neurological deficits was statistically higher in the hemiarch and arch group (17.5% vs. 8.4%, p = 0.045), the most common being stroke, and was also more frequent in the hemiarch and arch group than in the ascending aorta group (with statistical significance (15.7% vs. 6.5%)). The mean SF-12 physical score from the QoL questionnaire was higher in the ascending aorta replacement group than in the hemiarch and arch group (50.1 ± 7.3 vs. 44.0 ± 11.9, p = 0.017). Additionally, the mean SF-12 mental score was higher in the ascending aorta replacement group (52.3 ± 7.3 vs. 47.1 ± 12.8, p = 0.032). Conclusions: A more aggressive approach involving aortic arch repair means a lower survival rate and lesser quality of life after long-term follow-up in comparison with the replacement of the ascending aorta. If clinically applicable, a more defensive strategy may be considered.

暂无摘要。

UNASSIGNED: Postoperative gastrointestinal complications (GICs) were potentially fatal to patients who underwent aortic arch surgery. The aim of this study was to construct a prediction model of GICs.
UNASSIGNED: We retrospectively studied the medical records of 3063 patients who underwent aortic arch surgery. Patients were randomly divided into derivation and validation cohorts at a ratio of 4:1. A nomogram was constructed in the derivation cohort.
UNASSIGNED: A total of 157 patients with GICs were identified. In the derivation cohort, multivariate analysis identified six predictors of GICs including hypertension, ASA classification, preinduction MAP, aortic cross-clamp time, CPB time, and intraoperative transfusion of red blood cells. Compared with the patients without GICs, the patients with GICs had higher mortality, and longer ICU and hospital stays. We also divided the patients into four intervals according to the risk of GICs.
UNASSIGNED: This study developed a reliable prediction model of GICs after aortic arch surgery. This prediction model had been well verified in our research centre, and further external verification was required before it can be recommended for clinical application.

We herein describe our technique of \"branch first continuous perfusion arch repair (BF-CPAR)\" which does away with both cerebral circulatory arrest and the need for deep hypothermia. We use this technique for all aortic surgeries including for type A acute aortic dissections.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s12055-023-01535-2.

Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA.
This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events.
A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups.
This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.

BACKGROUND: Redo aortic arch surgery is complex and associated with higher risks and mortality. Prolonged mechanical ventilation (PMV) after cardiac surgery is linked to early adverse outcomes and increased costs.
OBJECTIVE: Identify specific risk factors and early complications associated with PMV following redo aortic arch surgery.
METHODS: Retrospective study at Fuwai Hospital involving 203 patients. Data on patient characteristics, intraoperative factors, and outcomes were analyzed.
RESULTS: A total of 203 patients were included, with 42.4 % requiring PMV. PMV patients had longer ICU stays (P < 0.001), lower discharge ADL scores (P < 0.001), and higher hospitalization costs (P < 0.001). While there was no significant difference in-hospital mortality between the two groups, the long-term survival rate in the PMV group was lower than that in the non-PMV group (P = 0.029). Multivariate analysis identified longer cardiopulmonary bypass time (OR 1.008, 95% CI, 1.002 - 1.014, P = 0.006), elevated intraoperative red blood cell transfusion(OR 1.214, 95% CI, 1.057 - 1.393, P = 0.006), higher PEEP (OR 1.296, 95% CI 1.089 - 1.542, P = 0.003), and total arch replacement (OR 3.241, 95% CI 1.392 - 7.543, P = 0.006) as independent risk factors for PMV.
CONCLUSIONS: PMV following redo aortic arch surgery is linked to early adverse outcomes, increased healthcare costs, and reduced long-term survival, with longer cardiopulmonary bypass times, elevated intraoperative red blood cell transfusion, higher PEEP, and total arch replacement as independent risk factors.

BACKGROUND: Decision making during aortic arch surgery regarding cannulation strategy and nadir temperature are important in reducing risk, and there is a need to determine the best individualized strategy in a data-driven fashion. Using machine learning (ML), we modeled the risk of death or stroke in elective aortic arch surgery based on patient characteristics and intraoperative decisions.
METHODS: The study cohort comprised 1323 patients from 9 institutions who underwent an elective aortic arch procedure between 2002 and 2021. A total of 69 variables were used in developing a logistic regression and XGBoost ML model trained for binary classification of mortality and stroke. Shapely additive explanations (SHAP) values were studied to determine the importance of intraoperative decisions.
RESULTS: During the study period, 3.9% of patients died and 5.4% experienced stroke. XGBoost (area under the curve [AUC], 0.77 for death, 0.87 for stroke) demonstrated better discrimination than logistic regression (AUC, 0.65 for death, 0.75 for stroke). From SHAP analysis, intraoperative decisions are 3 of the top 20 predictors of death and 6 of the top 20 predictors of stroke. Predictor weights are patient-specific and reflect the patient\'s preoperative characteristics and other intraoperative decisions. Patient-level simulation also demonstrates the variable contribution of each decision in the context of the other choices that are made.
CONCLUSIONS: Using ML, we can more accurately identify patients at risk of death and stroke, as well as the strategy that better reduces the risk of adverse events compared to traditional prediction models. Operative decisions made may be tailored based on a patient\'s specific characteristics, allowing for maximized, personalized benefit.

OBJECTIVE: The purpose of the study is to compare the short- and long-term outcomes of the frozen elephant trunk (FET) technique based on 2 different hybrid grafts implanted from January 2007 to July 2022.
METHODS: The study includes patients who underwent an elective or emergency FET procedure. Short-term, long-term mortality and freedom from thoracic endovascular aortic repair (TEVAR) were the primary end points. Analyses were carried out separately for the periods 2007-2012 and 2013-2022.
RESULTS: Of the 367 enrolled, 49.3% received E-Vita Open implantation and 50.7% received Thoraflex Hybrid implants. Overall mean age was 61 years [standard deviation (SD) = 11] and 80.7% were male. The average annual volume of FET procedures was 22.7 cases/year. Compared to E-Vita Open, patients implanted with Thoraflex Hybrid grafts were more likely to receive distal anastomosis in zone 2 (68.3% vs 11.6%, P < 0.001) with a shorter stent portion, mean = 103mm (SD = 11.3) vs mean = 149 mm (SD = 12.7; P < 0.001) and they underwent a reduced visceral ischaemia time, mean = 42.5 (SD = 14.2) vs mean= 61.0 (SD = 20.2) min, P < 0.001. In the period 2013-2022, overall survival at 1, 2 and 5 years was 74.8%, 72.5% and 63.2% for Thoraflex and 73.2%, 70.7% and 64.1% for E-Vita, without significant differences between groups (log-rank test = 0.01, P = 0.907). Overall freedom from TEVAR at 1, 2 and 5 years was 66.7%, 57.6% and 39.3% for Thoraflex and 79%, 69.7% and 66% for E-Vita, with significant differences between groups (log-rank test = 5.28, P = 0.029). In a competing risk analysis adjusted for chronic/residual aortic syndromes and stent diameter, the Thoraflex group was more likely to receive TEVAR during follow-up (subdistribution hazard ratio SHR = 2.12, 95% confidence interval 1.06-4.22).
CONCLUSIONS: The FET technique addresses acute and chronic arch disease with acceptable morbidity and mortality. Downstream endovascular reinterventions are very common during follow-up.