This study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique. Two-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each’s cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke. Overall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20–8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28–19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09–360.84; P = 0.044) as predictors for postoperative stroke. Stroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.

Background: Aim of this study was to report and to identify risk factors for distal aortic failure following aortic arch replacement via the frozen elephant trunk (FET) procedure.Methods: One hundred eighty-six consecutive patients underwent the FET procedure for acute and chronic aortic dissection. Our cohort was divided into patients with and without distal aortic failure. Distal aortic failure was defined as: (I) distal aortic reintervention, (II) aortic diameter dilatation to ≥ 6 cm or > 5 mm growth within 6 months, (III) development of a distal stent-graft-induced new entry (dSINE) and/or (IV) aortic-related death. Preoperative, intraoperative, postoperative and aortic morphological data were analyzed.Results: Distal aortic failure occurred in 88 (47.3%) patients. Forty-six (24.7%) required a distal reintervention, aortic diameter dilatation was observed in 9 (4.8%) patients, a dSINE occurred in 22 (11.8%) patients and 11 (6.4%) suffered an aortic-related death. We found no difference in the number of communications between true and false lumen (p = 0.25) but there were significantly more communications between Ishimaru zone 6–8 in the distal aortic failure group (p = 0.01). The volume of the thoracic descending aorta measured preoperatively and postoperatively within 36 months afterward was significantly larger in patients suffering distal aortic failure (p < 0.001; p = 0.011). Acute aortic dissection (SHR 2.111; p = 0.007), preoperative maximum descending aortic diameter (SHR 1.029; p = 0.018) and preoperative maximum aortic diameter at the level of the diaphragm (SHR 1.041; p = 0.012) were identified as risk factors for distal aortic failure.Conclusion: The incidence and risk of distal aortic failure following the FET procedure is high. Especially those patients with more acute and more extensive aortic dissections or larger preoperative descending aortic diameters carry a substantially higher risk of developing distal aortic failure. The prospective of the FET technique as a single-step treatment for aortic dissection seems low and follow-up in dedicated aortic centers is therefore paramount.

Objectives: Our aim was to investigate the occurrence and clinical consequence of postoperative in-stent thrombus formation following the frozen elephant trunk (FET) procedure.Methods: Postoperative computed tomography angiography (CTA) scans of all 304 patients following the FET procedure between 04/2014 and 11/2021 were analysed retrospectively. Thrombus size and location were assessed in multiplanar reconstruction using IMPAX EE (Agfa HealthCare N.V., Morstel, Belgium) software. Patients’ characteristics and clinical outcomes were evaluated between patients with and without thrombus formation.Results: During the study period, we detected a new postoperative in-stent thrombus in 19 patients (6%). These patients were significantly older (p = 0.009), predominantly female (p = 0.002) and were more commonly treated for aortic aneurysms (p = 0.001). In 15 patients (79%), the thrombi were located in the distal half of the FET stent-graft. Thrombus size was 18.9 mm (first quartile: 12.1; third quartile: 33.2). Distal embolisation occurred in 4 patients (21%) causing one in-hospital death caused by severe visceral ischaemia. Therapeutic anticoagulation was initiated in all patients. Overstenting with a conventional stent-graft placed within the FET stent-graft was the treatment in 2 patients (11%). Outcomes were comparable both groups. Female sex (p = 0.005; OR: 4.289) and an aortic aneurysm (p = 0.023; OR: 5.198) were identified as significant predictors for thrombus development.Conclusion: Postoperative new thrombus formation within the FET stent-graft is a new, rare, but clinically highly relevant event. The embolisation of these thrombi can result in dismal postoperative outcomes. More research is therefore required to better identify patients at risk and improve perioperative treatment.

Aims: To identify radiographic differences between patients with uncomplicated and complicated descending aortic dissections. Methods and results: Between April 2009 and July 2021, 209 patients with acute descending aortic dissections were analysed as complicated (malperfusion, rupture, diameter progress, and diameter ≥ 55 mm) or uncomplicated. Detailed CTA measurements (slice thickness ≤ 3 mm) were taken in multiplanar reconstruction. A composite endpoint (early aortic failure) was defined as reoperation, diameter progression, and early mortality. Seventy-seven patients were female (36.8%) [complicated n = 27 (36.5%); uncomplicated n = 50 (37.0%) P = 1.00]. Seventy-four (35%) patients were categorized as morphologically complicated, and 135 (65%) as uncomplicated. In patients with complicated dissections, the dissection extended more frequently to the aortic bifurcation (P = 0.044), the coeliac trunk (P = 0.003), the superior mesenteric artery (P = 0.007), and both iliac arteries (P < 0.001) originated less frequently from the true lumen. The length of the most proximal communication (entry) in type B aortic dissection was longer, 14.0 mm [12.0 mm; 27.0 mm] vs. 6.0 mm [4,0 mm; 13.0 mm] in complicated cases (P = 0.005). Identified risk factors for adverse aortic events were connective tissue disease [HR 8.0 (1.9–33.7 95% CI HR)], length of the aortic arch [HR 4.7 (1.5–15.1 95% CI HR)], a false lumen diameter > 19.38 mm [HR 3.389 (1.1–10.2 95% CI HR)], and origin of the inferior mesenteric artery from the false lumen [HR 4.2 (1.0–5.5 95% CI HR)]. Conclusion: We identified significant morphological differences and predictors for adverse events in patients presenting complicated and uncomplicated descending dissections. Our morphological findings will help guide future aortic therapies, taking a tailored patient approach.

Tim Berger, MD, Bartosz Rylski, MD, Martin Czerny, MD, MBA, Maximilian Kreibich, MD, MHBA; Selective antegrade cerebral perfusion: How to perfuse?, European Jou