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Objective This study aims to investigate the clinical manifestations, operative techniques, and outcomes of patients who undergo open repair after thoracic endovascular aortic repair (TEVAR). Methods From January 2010 to June 2022, 113 consecutive type A aortic dissection (TAAD) patients underwent secondary open operation after TEVAR at our institution, and the median interval from primary intervention to open surgery was 12 (1.9–48.0) months. We divided the patients into two groups (RTAD (retrograde type A dissection) group, N  = 56; PNAD (proximal new aortic dissection) group, N  = 57) according to their anatomical features. Survival analysis during the follow-up was evaluated using a Kaplan–Meier survival curve and a log-rank test. Results The 30-day mortality was 6.2% (7/113), the median follow-up period was 31.7 (IQR 14.7–65.6) months, and the overall survival at 1 year, 5 years, and 10 years was 88.5%, 88.5%, and 87.6%, respectively. Fourteen deaths occurred during the follow-up, but there were no late aorta-related deaths. Three patients underwent total thoracoabdominal aortic replacement 1 year after a second open operation. The RTAD group had a smaller ascending aorta size (42.5 ± 7.7 mm vs 48.4 ± 11.4 mm; P  < .01) and a closer proximal landing zone ( P  < .01) compared to the PNAD group. However, there were no differences in survival between the two groups. Conclusions TAAD can present as an early or a late complication after TEVAR due to stent-grafting-related issues or disease progression. Open operation can be performed to treat TAAD, and this has acceptable early and mid-term outcomes. Follow-up should become mandatory for patients after TEVAR because these patients are at increased risk for TAAD.

Background Acute Type A Aortic Dissection (aTAAD) is a severe and life-threatening condition. While animal studies have suggested that ketorolac could slow the progression of aortic aneurysms and dissections, clinical data on its efficacy in aTAAD patients remain limited. This study seeks to evaluate the safety and effectiveness of ketorolac in this patient group. Methods Patients were randomly assigned to receive either ketorolac or a placebo (0.9% saline). Treatment began at least 2 h prior to surgery (60 mg ketorolac or 2 ml saline administered once intramuscularly) and continued for 48 h post-surgery (30 mg ketorolac or 1 ml saline administered intramuscularly twice daily). The primary endpoints included assessing the safety and efficacy of ketorolac in improving the prognosis of aTAAD, focusing on mortality and organ malperfusion syndrome. Secondary endpoints included drug-related adverse events, blood test results, and other postoperative outcomes. Results Of 179 patients who underwent aTAAD repair, 110 met the inclusion criteria and were randomized into two groups of 55. One patient discontinued the intervention due to erythroderma on the first postoperative day, leaving 54 patients in the ketorolac group and 55 in the placebo group for analysis. No significant differences were found in the primary endpoints. However, the ketorolac group showed lower intraoperative bleeding (median: 1.8 L vs. 2.0 L, P  = 0.03), shorter intensive care unit (ICU) stays (median: 6.5 days vs. 8 days, P  = 0.04), and lower total hospital costs (median: ¥170,430 vs. ¥187,730, P  = 0.03). Conclusions Short-term ketorolac therapy did not alter the primary outcome but was associated with reduced intraoperative bleeding, shorter ICU stays, and potentially lower hospitalization costs. It demonstrates safety and a certain degree of effectiveness during the perioperative period. These findings suggest that ketorolac could be a viable option for perioperative management in patients with aTAAD. Trial registration The trial was registered at the Chinese Clinical Trial Register ( www.chictr.org.cn , No: ChiCTR2300074394).

The mortality and morbidity of emergency total aortic arch replacement (TAAR) for acute type A aortic dissection (ATAAD) is high, which is partly due to the excessively activated systemic inflammatory response. Methylprednisolone, an anti-inflammatory agent, might suppress the systemic inflammatory response and lead to improved outcomes. However, the protective effects of methylprednisolone on TAAR for ATAAD were not clarified. The usage and dosage varied in different centers across the world. The Medal trial is a prospective, multicenter, randomized, double-blind, placebo-controlled, parallel-group trial to evaluate whether 500 mg methylprednisolone IV before cardiopulmonary bypass could reduce the incidence of postoperative major organ injury, compared to placebo. Adult patients with the diagnosis with ATAAD, awaiting emergency total aortic arch replacement with hypothermic circulatory arrest and selective cerebral perfusion will be included in the trial. A total of 340 eligible subjects from 9 large cardiovascular centers will be randomized in a 1:1 ratio to receive 500 mg methylprednislone or placebo before cardiopulmonary bypass. The primary outcome is postoperative major adverse outcome [defined as all-cause death or postoperative neurological deficit or KDIGO II -III acute kidney injury or respiratory syndrome (tracheal intubation> 72 hours, tracheostomy or re-intubation) until postoperative day 30 or patient discharge]. The study has received approval from the local Ethics Committees of the 9 participating centers, and enrolled its first subject in June 24, 2022. As of September 5, 2024, 323 subjects have been enrolled. Results of the Medal trial will be published once data collection and analysis have been completed. The Medal trial will determine the effectiveness of 500 mg methylprednisolone on the outcomes of patients with ATAAD undergoing TAAR. URL https://www.chictr.org.cn/searchprojEN.html (Chinese Clinical Trial Registry). Unique identifier: ChiCTR2200059286

Objectives This study aimed to explore the feasibility of low-dose computed tomography (CT)–based mixed reality and its clinical role in type A aortic dissection (TAAD) operations. Methods Eighty-seven patients diagnosed with TAAD were prospectively enrolled and underwent thoracoabdominal aorta mixed reality. They were randomly divided into a low-dose mixed reality group, a conventional mixed reality group and a conventional thoracoabdominal aorta computed tomography angiography (CTA) group. Three-dimensional modelling, mixed reality and CT reconstruction technology were selected. The radiation dose and image quality were compared using Student’s t test. Doctors with different seniorities evaluated the clinical application value of thoracoabdominal aorta mixed reality using a Likert scale. The consistency was assessed using the Cohen kappa coefficient ( k ). The Pearson chi-square test was used to test the correlation of perioperative index results in TAAD operations. Results Low-dose CT technology can be effectively applied to thoracoabdominal aorta mixed reality and reduces the radiation dose by approximately 59% and the operation time and auxiliary cardiopulmonary bypass time by approximately 22% and 29%, respectively. The subjective scores of doctors with different seniorities on the clinical application value of thoracoabdominal aorta mixed reality were higher than those of thoracoabdominal aorta CTA (all p > 0.05). Conclusions Low-dose CT can be effectively used in thoracoabdominal aortic mixed reality to reduce the radiation dose while ensuring quality. Low-dose thoracoabdominal aortic mixed reality has clinical application value and can effectively reduce the operation time and auxiliary cardiopulmonary bypass time in TAAD operations. Key Points • Low-dose CT technology can ensure the mixed reality quality of the thoracoabdominal aorta with a radiation dose reduction of approximately 59%. • Compared with thoracoabdominal aorta CTA, low-dose thoracoabdominal aorta mixed reality can reduce the operation time and auxiliary cardiopulmonary bypass time by approximately 20% and 29%, respectively, in TAAD operations. • The application value of low-dose thoracoabdominal aorta mixed reality in operation scheme formulation, operation risk assessment, operation navigation and diagnosis and treatment under safe distance was greater than that of thoracoabdominal aorta CTA in TAAD.

Background This study aims to compare the clinical effects of two distinct surgical approaches, namely 3D printing-assisted extracorporeal pre-fenestration and Castor integrated branch stent techniques, in treating patients with Stanford type B aortic dissections (TBAD) characterized by inadequate proximal landing zones. Methods A retrospective analysis was conducted on 84 patients with type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) reconstruction at our center from January 2022 to July 2023. Based on the different surgical approaches, the patients were divided into two groups: the group assisted by 3D printing for extracorporeal pre-fenestration ( n  = 44) and the group using the castor integrated branch stent ( n  = 40). Clinical indicators: including general patient information, operative time, surgical success rate, intraoperative and postoperative complication rates, re-intervention rate, and mortality, as well as postoperative aortic remodeling, were compared between the two groups. The endpoint of this study is the post-TEVAR mortality rate in patients. Results The surgical success rate and device deployment success rate were 100% in both groups, with no statistically significant difference ( P  > 0.05). However, the group assisted by 3D printing for extracorporeal pre-fenestration had a significantly longer operative time (184.20 ± 54.857 min) compared to the group using the castor integrated branch stent (152.75 ± 33.068 min), with a statistically significant difference (t = 3.215, p  = 0.002, P  < 0.05). Moreover, the incidence of postoperative cerebral infarction and beak sign was significantly lower in the group assisted by 3D printing for extracorporeal pre-fenestration compared to the castor-integrated branch stent group, demonstrating statistical significance. There were no significant differences between the two groups in terms of other postoperative complication rates and aortic remodeling ( P  > 0.05). Notably, computed tomography angiography images revealed the expansion of the vascular true lumen and the reduction of the false lumen at three specified levels of the thoracic aorta. The follow-up duration did not show any statistically significant difference between the two groups (10.59 ± 4.52 vs. 9.08 ± 4.35 months, t = 1.561, p  = 0.122 > 0.05). Throughout the follow-up period, neither group experienced new endoleaks, spinal cord injuries, nor limb ischemia. In the castor-integrated branch stent group, one patient developed a new distal dissection, prompting further follow-up. Additionally, there was one case of mortality due to COVID-19 in each group. There were no statistically significant differences between the two groups in terms of re-intervention rate and survival rate ( P  > 0.05). Conclusion Both 3D printing-assisted extracorporeal pre-fenestration TEVAR and castor-integrated branch stent techniques demonstrate good safety and efficacy in treating Stanford type B aortic dissection with inadequate proximal anchoring. The 3D printing-assisted extracorporeal pre-fenestration TEVAR technique has a lower incidence of postoperative cerebral infarction and beak sign, while the castor-integrated branch stent technique has advantages in operative time.

Background Nosocomial infection (NI) is one of the most common complications after acute aortic dissection surgery (AADS) and contributes significantly to mortality and length of hospital stay. Therefore, this study analysed the clinical characteristics of NI and determined the risk factors for the occurrence and development of NI and in-hospital outcomes. Methods During this study, 429 adult patients with AADS were divided into an infected group ( n  = 141) and a noninfected group ( n  = 288). Complete clinical data (including baseline clinical characteristics and laboratory results, surgery-related variables, and clinical outcomes) were collected for statistical analysis. Multivariate logistic regression was used to determine the independent risk factors for the occurrence of NI after AADS. Results The incidence of NI in AADS was 29.0%. The main clinical presentations were hospital-acquired pneumonia (HAP = 51.8%), ventilator-associated pneumonia (VAP = 24.8%) and bloodstream infection (BSI = 18.4%). The most common pathogenic bacteria were gram-negative bacilli (GNB = 68.8%), including Klebsiella pneumoniae (27.7%), Pseudomonas aeruginosa (16.3%) and Acinetobacter baumannii (13.5%). Multivariate regression analysis found that preexisting cerebrovascular disease, lower estimated glomerular filtration rate (eGFR), total protein and serum albumin, longer operation time and cardiopulmonary bypass (CPB) time, second operation in-hospital, exposure to extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), and proton pump inhibitor (PPI) use were independent risk factors for the occurrence of NI (all P  < 0.01). Compared with noninfected patients, the intensive care unit (ICU) stay time and total hospital stay time were significantly prolonged after the occurrence of NI (all P  < 0.001). The risks of other complications, such as acute kidney injury (AKI), acute upper gastrointestinal haemorrhage, new cerebral infarction, paraplegia or hemiplegia, and new cerebral haemorrhage, were significantly higher in patients with NI after AADS than in noninfected patients (all P  < 0.001). The in-hospital mortality (46.1%) of NI after AADS was significantly higher than that of noninfected patients (3.5%, P  < 0.001). Conclusions This study identified the high morbidity and mortality of NI after AADS. The most common types of infection were HAP, VAP and BSI, and the pathogenic microorganisms were Klebsiella pneumoniae , Pseudomonas aeruginosa and Acinetobacter baumannii . Total protein, serum albumin, eGFR, longer operation time and CPB time, second operation in-hospital, exposure to ECMO and CRRT, and PPI use were independent risk factors for the occurrence of NI.

Objective To compare the application and outcomes of femoral versus axillary arterial cannulation in adult patients undergoing surgery for type A aortic dissection. Methods We conducted a retrospective review of 108 patients who underwent surgery for type A aortic dissection, dividing them into two groups based on the type of arterial cannulation utilized: the femoral artery cannulation group ( n  = 53) and the axillary artery cannulation group ( n  = 55). We assessed their general condition, cardiopulmonary bypass time, and the occurrence of major postoperative complications. Multivariate logistic regression models were used to identify independent predictors of mortality risk factors. Results The operative mortality rates were comparable between the two groups, with axillary cannulation at 18.1% and femoral cannulation at 15.1%. Multivariate logistic analysis identified age (70 years or older) and prolonged extracorporeal cardiopulmonary bypass time (250 min or more) as independent risk factors for surgical mortality. The rates of early stroke, renal injury, and cognitive dysfunction were similar in both groups. Conclusion The findings indicate that femoral and axillary arterial cannulation yield similar outcomes in patients with acute type A aortic dissection. The choice of cannulation site should be individualized based on each patient’s specific risk factors. Additionally, preoperative hemodynamic instability, the duration of cardiopulmonary bypass (CPB), and a high body mass index (BMI ≥ 30 kg/m²) are independent predictors of operative mortality.

Background During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, the organs in the lower body, such as the viscera and spinal cord, are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood. Methods This study is designed as a multicenter, computer-generated, randomized controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS. A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, which will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, which will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. All patients will be analyzed according to the intention-to-treat protocol. Discussion This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS. Trial registration Clinicaltrials.gov, ID: NCT03607786 . Registered on 30 July 2018.

Background To investigate the clinical effects and safety of the hybrid debranching technique for patients with acute Stanford type A aortic dissection (AD). Methods One hundred nine patients with acute Stanford type a AD were selected and divided into observation group and control group according to the different surgical methods. Fifty-five patients in the observation group were treated with hybrid debranching, and 54 patients in the control group were treated with Sun’s operation. The operation duration, clamp time, cardiopulmonary bypass duration, volume of blood transfusion, ventilator application duration, duration of stay in the intensive care unit, aortic rupture, second thoracotomy due to hemorrhage, gastrointestinal hemorrhage, stroke, paraplegia, renal failure, and all-cause mortality were recorded. Postoperative follow-up was conducted. The number of cases that underwent follow-up and the number of cases with complete thrombosis of the false aneurysm cavity detected by computed tomography angiography (CTA) was recorded. Results The surgical success rate was 100% in both groups, and there were no cases with unplanned secondary surgery. Compared with the control group, only the difference in the volume of blood transfusion was not significantly significant between the two groups ( P  = 0.052), while the rest of the observation indicators were significantly lower in the observation group than in the control group ( P  < 0.001 for all). The proportion of cases with complete thrombosis of the false aneurysm cavity was significantly higher in the observation group than in the control group at 3 and 6 months after surgery ( P  < 0.05). Conclusion In patients with acute Stanford type A AD involving the arch, the hybrid debranching technique was safe and effective. It was recommended for patients with advanced age and a high risk of intolerance to deep hypothermic circulatory arrest.

Background Acute kidney injury (AKI) is a frequent and serious complication following surgery for acute type A aortic dissection (ATAAD). Nitric oxide (NO) may reduce AKI incidence through renal-protective mechanisms, but evidence in the ATAAD population remains limited. This trial aims to evaluate whether perioperative administration of NO can reduce the incidence of postoperative AKI in this population. Methods This single-center, randomized, parallel-group superiority trial will enroll 106 adult patients undergoing ATAAD emergency surgery. Participants will be randomly allocated in a 1:1 ratio to either receive 60 parts per million of NO during cardiopulmonary bypass and for 12 h post-surgery, or to receive standard care without NO. The primary outcome is AKI incidence within 48 h postoperatively, defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary outcomes include AKI severity, urine output, vasoactive-inotropic score, neutrophil gelatinase-associated lipocalin levels, sequential organ failure assessment score, ventilator support duration, intensive care unit (ICU) and hospital length of stay, and major adverse kidney events, cumulative mediastinal and pericardial drainage volume. Discussion This trial will evaluate whether perioperative NO administration can reduce early AKI and improve renal and clinical outcomes in high-risk ATAAD patients. Findings may provide evidence for a novel nephroprotective strategy in aortic surgery. Trial registration ClinicalTrials.gov NCT06622291. Registered on June 26, 2024.