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 I ² 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.

An aorto-esophageal fistula (AOF) is a pathological communication between the thoracic aorta and the esophagus. It can induce life-threatening hematemesis, which is unique among the other types of gastrointestinal hemorrhage in that the vomiting is bright red and represents an arterial bleed. Nevertheless, it is notable that over 70% of cases are associated with thoracic aortic aneurysms, particularly as a postoperative complication following open surgery, and arguably more so following endovascular repair. As thoracic endovascular aortic repair becomes a more common practice, it is important to remain vigilant for an increase in the incidence of AOF. A thorough consideration of potential AOF etiologies is essential, as these must be substantiated by clinical, laboratory, and imaging tests. The available management options and the likelihood of success depend largely on the diagnosis made. The stability of the fistula wall is fundamental to determine treatment options and is particularly important in case of a potentially fatal AOF. The stability of the organ wall determines the complication risk, and therefore which treatment the patient is most likely to tolerate. A new AOF classification system will allow for better diagnosis and clearer assessment of treatment options.

Purpose: To assess outcomes of a low-profile thoracic stent-graft in the treatment of thoracic aortic pathologies. Methods: A retrospective analysis of all consecutive patients with aortic thoracic pathologies treated with the RelayPro device in two university hospitals between October 2018 and July 2019. Results: 23 patients (65% men; mean age 63.4 ± 15 years) were treated. Pathologies included aortic dissections (n = 10), 5 residual type A (22%) and 5 type B (22%), 6 degenerative aortic aneurysms (26%), 4 penetrating aortic ulcers (17%), and aortic erosion, intramural hematoma and aortic rupture (n = 1 and 4% in each case). Two cases (9%) were emergent and two urgent. Proximal landing was achieved in zones 0 (4%), 1 (4%), 2 (43%), and 3 (26%). Five grafts were frozen elephant trunk extensions. Technical success was 100% with accurate device deployment in the intended landing zone of the aortic arch in all 23 patients and with no Ia/III endoleaks and three (13%) type II endoleaks. Apposition was adequate in 96%. Two patients had post-implantation syndromes (one fever, one leukocytosis). Mean follow-up was 11.6 ± 3.7 months (range, 2–16) with no other complications, secondary interventions or conversions to open surgery. There was no 30-day mortality and no aortic-related mortality; all-cause mortality was 4% during follow-up. Conclusion: A 3–4 French reduced profile in the current generation of stent-grafts facilitates TEVAR particularly in patients with smaller vessels access. Early safety and effectiveness outcomes are favorable, even in endpoints such as deployment accuracy and apposition which may be surrogates for longer-term clinical success and durability.

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. 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. 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. 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.

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.

Background: A paradox of lower morbidity and mortality in overweight or obese patients undergoing cardiac surgery has been described; however, knowledge about the influence of obesity in patients with acute Type A aortic dissection (AAD) is limited. This study aimed to evaluate the effect of obesity on short- and long-term outcomes after surgical treatment for AAD. Methods: Between 01/2004 and 12/2022, 912 patients with a BMI of 18.5 or greater were operated on for AAD. Patients were grouped according to their BMI (normal weight: BMI 18.5–24.9, n = 332; overweight: BMI 25–29.9, n = 367; obesity class I: BMI 30–34.9, n = 133; obesity class II+: BMI ≥ 35, n = 67), and the obtained clinical and surgical data were compared. Results: Obese patients were younger at the time of AAD (p = 0.001) and demonstrated higher rates of typical cardiovascular comorbidities (arterial hypertension, p = 0.005; diabetes mellitus, p < 0.001). The most important preoperative parameters, as well as the surgical approach, were similar between all four groups. The occurrence of renal failure requiring dialysis was higher in patients with BMI ≥ 35 (p = 0.010), but the in-hospital (p = 0.461) and long-term survival (p = 0.894) showed no significant differences. Conclusions: There are no indications that the obesity paradox is applicable in the setting of AAD. Since obese patients are affected by AAD at a younger age, obesity might constitute a risk factor for AAD. However, obesity does not influence short- or long-term survival. Regardless of body weight, immediate surgical therapy remains the treatment of choice for AAD.