Thoracic aortic dissection (AD) is associated with increased morbidity and mortality. Acute aortic syndrome is the first presentation of the disease in most cases. While acute AD management follows concrete guidelines because of its urgent and life-threatening nature, chronic AD is usually overlooked, although it concerns a wide spectrum of patients surviving an acute event. Acute AD survivors ultimately enter a chronic aortic disease course. Patients with chronic thoracic AD (CTAD) require lifelong surveillance and a proportion of them may present with symptoms and late complications demanding further surgical or endovascular treatment. However, the available data concerning the management of CTAD is sparse in the literature. The management of patients with CTAD is challenging as far as determining the best medical therapy and deciding on intervention are concerned. Until recently, there were no guidelines or recommendations for imaging surveillance in patients with chronic AD. The diagnostic methods for imaging aortic diseases have been improved, while the data on new endovascular and surgical approaches has increased significantly. In this review, we summarize the current evidence in the diagnosis and management of CTAD and the latest recommendations for the surgical/endovascular aortic repair of CTAD.

Background: Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis or Libman–Sacks endocarditis, is a rare non-infectious condition affecting mostly the left-sided heart valves of patients who, most often, suffer from malignancies and connective tissue disorders. Herein, we present a case of a male patient with marantic endocarditis due to occult lung adenocarcinoma. Case presentation: The patient fulfilled the modified Duke’s criteria of possible bacterial endocarditis of the aortic valve; however, multiple blood cultures and serological tests were negative. In addition, the patient’s clinical course was constantly deteriorating. Thus, a fluorodeoxyglucose-positron emission tomography (FDG-PET) scan was conducted. This examination revealed multiple positive thoracic lymph node groups, as well as a positive lung lesion. The patient underwent aortic valve replacement and lymph biopsies during the operation established the diagnosis of solid/micropapillary lung adenocarcinoma and consequently of the non-bacterial thrombotic endocarditis. Conclusions: Advanced imaging techniques may be needed to diagnose NBTE and should be kept in mind when the Duke criteria are not definite. Clinical suspicion is key to implement these premises. However, the exact role of the PET-scan has yet to be specified.

The Frozen Elephant Trunk (FET) technique is indicated in acute aortic syndromes with arch involvement and malperfusion of tissues. We sought to report on long-term outcomes of FET in emergent cases of acute aortic syndromes. Methods: Twenty-three adult patients were referred to our department for surgical management of acute aortic syndromes and underwent aortic arch replacement using the FET technique between November 2010 and January 2022. The primary outcome was long-term survival. Secondary outcomes were the 30-day mortality rate and the incidence of neurologic complications, i.e., stroke and spinal cord ischemia. Results: The mean patient age was 57.1 (±12.5) years, and the majority (20 patients, 87%) were male. The most common indication was Stanford type A acute aortic dissection (aTAAD) in 17 (74%) patients, followed by non-A non-B dissection in 2 (8.7%) patients, penetrating aortic ulcer (PAU) of the aortic arch in 2 (8.7%) patients, type A intramural hematoma (IMH) in 1 (4.3%) patient and blunt thoracic aortic injury of the aortic arch in 1 (4.3%) patient. Kaplan–Meier survival analysis revealed a 73% survival at 12 months, which persisted up to 11 years of follow-up. Conclusion: The FET technique provides a reliable solution for surgical management of patients with acute aortic syndromes. Excellent, sustained long-term results can be achieved.

Background: Competitive flow (CF) in coronary artery bypass grafting (CABG) occurs when graft flow is impaired due to higher competing flow from either the native circulation or another graft and may result in functional graft occlusion. We report a case of functional graft occlusion of a left internal mammary artery (LIMA) due to flow competition with a saphenous vein graft (SVG) and discuss the rationale of ligating the graft responsible for the CF. Case presentation: The case refers to a 56-year-old man with an isolated subtotal ostial left anterior descending (LAD) lesion who underwent conventional double on-pump CABG with an in situ (LIMA) to the LAD and a centrally anastomosed SVG to the Diagonal branch (D1). Concerning the initial Transit-time flow measurements (TTFM), the SVG had a mean graft flow (MGF) of 49 ml/min, a Pulsatility index (PI) of 1 and a Diastolic flow (DF) of 66%. The LIMA graft had an MGF of 31 ml/minute, a PI of 3.8, a DF of 80%, but a Backward flow (BF) of 8%. As the LIMA BF was quite high, we suspected competitive flow of the graft and thus decided to transiently apply a bulldog clamp to the SVG, to check if the LIMA TTFM would change. Indeed, MGF was 44 ml/minute, the PI was 2.3, DF was 60%, and BF was 0.9%. Despite these results, the operating surgeon did not alter the revascularization plan and the operation was finished. The patient was discharged uneventfully. However, in a 6-month follow-up, the patient was symptomatic and with poor ejection fraction, and the diagnostic work-up revealed the functional occlusion of the LIMA graft with a string sign, and a patent SVG. After Heart Team consultation and patient update, he underwent left main stent implantation. Conclusions: There should be a great degree of suspicion for CF with high BF values, even when the rest of the parameters measured during TTFM are normal or marginal. Also, the location of the LAD stenosis proximal to the D1 is a risk factor for CF when both arteries are grafted. Changing the revascularization plan based on TTFM is warranted for optimal outcomes.