Non-A non-B aortic dissection remains a complex and controversial topic in cardiovascular management, eliciting varied approaches among cardiologists and surgeons. Due to the limited evidence surrounding this condition, existing guidelines are limited in the complexity of their recommendations. While most patients are initially managed medically, invasive treatment becomes necessary in a large proportion of patients. When surgery is considered, the most utilized techniques include the frozen elephant trunk procedure and endovascular repair strategies targeting the arch and descending thoracic aorta. This narrative review aims to synthesize current knowledge and clinical experiences, highlighting the challenges and evolving practices related to non-A non-B dissection management.

Background/Objectives: Physician-modified endografts (PMEGs) have emerged as a treatment option for complex aortic pathologies. Uncertainty remains regarding the modification techniques and the most suitable materials for customization of fenestrated endografts. The aim of this study was to evaluate CE-marked endovascular aortic repair (EVAR) devices and suitable materials for device modification in PMEGs for juxtarenal and pararenal aortic pathologies. Methods: This single-center observational study included patients treated with the physician-modified TREO (Terumo Aortic, Inchinnan, UK) device between April and December 2024. All patients had aortic ruptures or symptomatic aneurysms and unfavorable anatomy or severe comorbidities, making standard EVAR and open repair unsuitable. Procedural data were recorded and analyzed, including in-hospital outcomes. The “wire visibility” and “sheath–wire contrast” of endografts were assessed under fluoroscopy, and different resheathing techniques were compared. Results: Technical success was achieved in all five patients. The number of fenestrations per patient was 2.6 (range: 1–4). In one patient (1/5), type Ib and type IIIc endoleaks were observed postoperatively, requiring reintervention. No in-hospital mortality occurred. The ICU and hospital stay were 24 h (range: 18–40 h) and 8 days (range: 6–20 days), respectively. Moreover, the One SNARE wire was identified as the wire with the highest “wire visibility”, and Endurant II showed the best “sheath–wire contrast”. Resheathing with the dedicated crimping device was superior to the tape-assisted method. Conclusions: The TREO platform, in synergy with suitable additional materials, offers a viable solution for urgent aortic pathologies requiring PMEGs. Continued refinement of materials and procedural standardization could enhance the long-term outcome.

Background and Objectives: This study aimed to evaluate the impact of body mass index (BMI) on post- operative outcomes in patients undergoing aortic arch repair with the frozen elephant trunk technique (FET). Materials and Methods: A total of 387 patients who underwent an FET procedure between 04/2014 and 11/2024 were retrospectively analyzed. Patients were divided into four groups according to BMI: underweight (BMI < 18.5, n = 12) normal weight (BMI: 18.5 to <25, n = 150), overweight (BMI: 25 to <30, n = 154), and obese (BMI: ≥30, n = 71). Patient characteristics and clinical outcomes were compared across groups. Multivariable Cox regression, interaction analysis, and restricted cubic spline modelling were performed using R (Version 4.4.3). Results: Interaction analysis revealed BMI-dependent effect modification for several predictors. Insulin-dependent diabetes mellitus was associated with increased mortality only in patients with BMI < 25 kg/m² (interaction p = 0.003). Transfusion of packed red blood cells (PRBCs) also showed a significant interaction with BMI (p = 0.016), with a stronger effect in patients with BMI < 25 kg/m², although significant in both strata. Moreover, cross-clamp time demonstrated a BMI-dependent interaction (p = 0.047), with numerically higher mortality hazards in overweight patients (BMI > 25 kg/m²), but without statistically significant subgroup effects. Spline analysis indicated a non-linear, threshold-based association between overall mortality and BMI but does not reach statistical significance. Kaplan–Meier analysis showed no significant difference in 5-year survival among BMI categories. Conclusions: BMI should not be used as a primary risk stratification tool for survival after an FET procedure. Rather, attention should be paid to comorbid conditions and intraoperative factors that interact with BMI. For patients with lower BMI (25 kg/m²). Future studies should aim to clarify the impact of BMI on outcomes after FET, particularly in the context of patient selection and perioperative optimization strategies.

To report outcomes after the use of the Omniflow II biosynthetic graft (LeMaitre Vascular, Il, United States) for vascular reconstruction in patients with prosthetic infection at the aorto-iliac and femoropopliteal level. Within a 6-year period, all consecutive patients with aorto-iliac and femoropopliteal graft infection treated by resection of the infected graft material, extensive local debridement, and reconstruction using Omniflow II biosynthetic graft were retrospectively analyzed. Patient characteristics, intraoperative details, postoperative outcomes, and infection details were assessed. Overall 18 patients were operated in the study period. The anatomical localization of the index surgery was the abdominal aorta n = 3 (17%), iliac arteries n = 5 (27%), and lower extremities (thigh) n = 10 (56%). Previous surgery included 8 (44%) reconstructions with alloplastic and 10 (55.6%) reconstructions with bovine xenopericardium. An obturator rerouting for the aorto-iliac level was used in eight patients (44%), a femorofemoral crossover routing was used in seven patients (39%), and a femoropopliteal routing was used in three patients (17%). Overall, three patients (17%) expired in hospital. Five (28%) patients required secondary wound closure. Operative revision due to bleeding was performed in 3 patients. During follow-up (mean 41.4 ± 25.7 months), 1 patient received a stent angioplasty to maintain graft patency. We observed 1 reinfection (6%), treated by explanation of the prosthesis, and no further revascularization was performed. Secondary graft patency was 100%, and 1 reintervention at the level of the foramen obturatum was needed. The concept of using the Omniflow II biosynthetic graft for vascular reconstruction in patients with prosthetic infection at the aorto-iliac and femoropopliteal level shows very promising midterm results. Graft patency is high and reinfection rate is low.

The aim of this study was to compare the 2 intraoperative shunting techniques (proximal vs. distal) during eversion endarterectomy (EEA) of the internal carotid artery (ICA). All patients operated between January 2011 and December 2022 who received routine shunting of the ICA were enrolled in this retrospective study. Patients undergoing selective shunting, patch angioplasty of the ICA, redo surgeries, or surgery performed by a resident were excluded. Intraoperative shunt placement took place after completing the eversion of the ICA. The patients were divided into 2 groups based on shunt placement technique: (i) distal shunting, where the shunt was firstly inserted into the ICA and then into the common carotid artery, and (ii) proximal shunting, where the shunt was firstly inserted into the common carotid artery and then into the ICA. Propensity score matching was used to compare the 2 groups. All procedures were performed under general anesthesia, with regional cerebral oxygenation monitoring. The primary end point was the incidence of perioperative stroke and in-hospital mortality. A total of 658 thromboendarterectomies of the ICA using intraoperative shunt were performed during the study period. Proximal shunting was used in 330 (50.2%) and distal shunting in 328 (49.8%). Using the propensity score matching, 260 pairs were generated for analysis. The perioperative stroke rate was significantly higher in the proximal shunting group, n = 13 (5%), compared to the distal shunting group, n = 4 (1.5%), (P < 0.05). The overall in-hospital mortality incidence was 0.6% (n = 3) (n = 2 in the proximal shunting group and n = 1 in the distal shunting group, P = 0.99). In the setting of an elective shunting of the ICA during EEA, the proximal first placement of the shunt may cause a higher incidence of perioperative stroke compared to the distal first placement of the stunt. A distal first shunting strategy seems reasonable when performing EEA surgery to improve patient outcomes.