OBJECTIVES We compared the results of 2 groups of patients who underwent aortic arch replacement with the frozen elephant trunk technique. In the first group, the distal anastomosis was performed in arch zone 2; in the second control group, the distal anastomosis was performed in arch zone 3. METHODS Between January 2007 and April 2018, the frozen elephant trunk technique was used in 282 patients. The median age was 62 years (range 18–83 years), and 233 patients were men (82.6%). Two different frozen elephant trunk prostheses were used: the Jotec E-vita open prosthesis in 167 patients (59.2%) and the Vascutek Thoraflex hybrid prosthesis in 115 patients (40.8%). Patients were divided into 2 groups according to the distal anastomosis site: zone 2 group (69 patients) and zone 3 group (213 patients). The main indications were chronic aortic dissection (n = 164, 58.2%), degenerative aneurysm (n = 72, 25.5%) and acute aortic dissections (n = 45, 16%). RESULTS The overall in-hospital mortality rate was 17%: 20% for the zone 2 group and 16% for the zone 3 group, without significant differences, also in terms of cardiopulmonary bypass and myocardial ischaemia times. However, the visceral ischaemia time was significantly shorter for the zone 2 group, whereas the antegrade selective cerebral perfusion time was significantly longer for the same group. Recurrent laryngeal nerve injury rate was lower in the zone 2 group. The overall postoperative paraplegia rate was 3.5%, whereas the occurrence of permanent neurological dysfunction and dialysis was 9% and 19%, respectively, with no significant differences between the groups. CONCLUSIONS ‘Proximalization’ of the distal anastomosis can be used for arch reconstruction, especially in complex cases such as reoperations or acute aortic dissections. Furthermore, with the aid of branched hybrid grafts, a reduction of the visceral ischaemia time is achieved.

The development of the frozen elephant trunk (FET) technique for a simplified treatment of complex lesions of the thoracic aorta originated as an evolution of the classic elephant trunk technique, described for the first time by Borst et al. [1] in 1983. Novel technologies and standardization of the surgical approach produced a progressive improvement of early and late outcomes. Most of the time and for specific indications, FET procedure allows physicians to treat lesions involving extensive portions of the thoracic aorta in one single step. Spinal cord injury remains one of the main complications of this procedure, even though spinal protection strategies have led to better results. We hereby report our opinions and recommendations based on our experience started in 2007.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease with a very complex pathophysiology differing from other causes of pulmonary hypertension (PH). It is an infrequent consequence of acute pulmonary embolism that is frequently misdiagnosed. Pathogenesis has been related to coagulation abnormalities, infection or inflammation, although these disturbances can be absent in many cases. The hallmarks of CTEPH are thrombotic occlusion of pulmonary vessels, variable degree of ventricular dysfunction and secondary microvascular arteriopathy. The definition of CTEPH also includes an increase in mean pulmonary arterial pressure of more than 25 mmHg with a normal pulmonary capillary wedge of less than 15 mmHg. It is classified as World Health Organization group 4 PH, and is the only type that can be surgically cured by pulmonary endarterectomy (PEA). This operation needs to be carried out by a team with strong expertise, from the diagnostic and decisional pathway to the operation itself. However, because the disease has a very heterogeneous phenotype in terms of anatomy, degree of PH and the lack of a standard patient profile, not all cases of CTEPH can be treated by PEA. As a result, PH-directed medical therapy traditionally used for the other types of PH has been proposed and is utilized in CTEPH patients. Since 2015, we have been witnessing the rebirth of balloon pulmonary angioplasty, a technique first performed in 2001 but has since fallen out fashion due to major complications. The refinement of such techniques has allowed its safe utilization as a salvage therapy in inoperable patients. In the present keynote lecture, we will describe these therapeutic approaches and results.

Background We evaluated the clinical and anatomic presentations of acute type A aortic dissection according to patient age. Methods We retrospectively reviewed 235 consecutive patients who underwent acute type A dissection repair between January 2000 and December 2014. The influence of age on anatomical and clinical presentation, surgical management in the entire cohort and also after exclusion of patients with known connective tissue disorders was assessed using logistic regression. Results Males presented with type A acute aortic dissection at a younger age than females. Acute onset with signs of myocardial ischemia, connective tissue disorders, or bicuspid aortic valve characterized the younger population. Extension to the coronary sinus(es) ( p = 0.0003), descending thoracic aorta ( p = 0.016), and abdominal aorta ( p = 0.029), and an intimal tear at the level of the aortic root ( p = 0.0017) correlated inversely with patient age. Similar findings were obtained after exclusion of patients with connective tissue disorders or a bicuspid aortic valve. Conclusions More frequent proximal and distal progression of the dissection flap occurs in younger patients with acute type A aortic dissection. Older age is associated with a lower probability of an intimal tear at the level of the sinus of Valsalva. These findings, associated with prognostic implications, account for the choice of more radical proximal procedures for repair of aortic dissection in younger patients.

A n 82-year-old woman was admitted to our institution after stabbing herself with a knitting needle through her right supraclavicular fossa. Computed tomography showed the needle penetrating the aortic arch at the origin of the left subclavian artery. The exit point was in the descending aorta, corresponding to the eighth thoracic vertebral body ( Fig 1A). A large left hemothorax and extensive mediastinal hemorrhages surrounding the aortic arch were present ( Figs 1B, 1C, 1D).The patient was hemodynamically stable. Treatment options were discussed with the involvement of cardiothoracic surgeons, interventional radiologists, and vascular surgeons. Given the complexity of a potential surgical repair, a complete endovascular approach was proposed, with immediate surgical support as required.Under general anesthesia, a 24F delivery sheath was advanced through the right common femoral artery and a 37 Â 150 mm GORE TAG stent graft (W. L. Gore & Associates, Flagstaff, AZ) was deployed under permissive hypotension, preserving the left common carotid artery ostium ( Fig 1E). The left subclavian artery origin was then embolized with 0.035-inch coils through percutaneous left brachial artery access, preserving the origin of the left vertebral artery. The knitting needle was then withdrawn under fluoroscopy. Completion angiography demonstrated successful repair and preservation of flow to the left subclavian artery through retrograde flow in the left vertebral artery ( Fig 1F).Strong teamwork and multidisciplinary collaboration of cardiothoracic surgeons, interventional radiologists, and vascular surgeons provided successful treatment of this peculiar case. Fig 1.