Objective To summarize our experience and the early and midterm outcomes of stented elephant trunk procedure for right-sided aortic arch (RAA) with Kommerell's diverticulum (KD). Methods From April 2013 to July 2020, patients with RAA and KD who underwent stented elephant trunk procedure at our center were collected. Surgery was performed under moderate hypothermic circulatory arrest combined with selective antegrade cerebral perfusion via median sternotomy. Results A total of 8 patients were included, including 7 males and 1 female with a mean age of 51.88±9.61 years. All patients had an aneurysmal KD and aberrant left subclavian artery. Preoperative comorbidities included acute Stanford type B aortic dissection in 1 patient, aortic arch pseudoaneurysm in 1 patient, acute type B intramural hematoma in 2 patients, and coronary artery disease in 1 patient. Concomitant procedures included reconstruction of the left subclavian artery in all patients and coronary artery bypass grafting in 1 patient. The mean time of operation, cardiopulmonary bypass, aortic cross-clamping, and selective cerebral perfusion was 6.25±1.16 h, 157.75±40.07 min, 77.75±33.10 min, and 28.50±5.55 min, respectively. No intraoperative death occurred. There was 1 in-hospital death. Follow-up was completed in all patients with a mean period of 3.58±2.08 years. No late death occurred. A persistent anastomotic leak of the proximal arch was detected in 1 patient, but reintervention was not performed because neither aortic dilatation nor symptoms of tracheal and esophageal compression were observed during the follow-up. The remaining 6 patients showed positive aortic remodeling with complete thrombosis of the aneurysmal KD, and neither aortic event nor tracheal and esophageal compression occurred. Conclusion Stented elephant trunk procedure is a safe and feasible technique for selected patients with RAA and KD, which can achieve favorable early and midterm outcomes.

Objective:To explore surgical strategies for acute type A aortic dissection involving severe stenosis or occlusion of the carotid arteries.Methods:From January 2019 to March 2023, a total of 29 patients with acute type A aortic dissection involving severe stenosis or occlusion of the carotid arteries were included in the study. All patients underwent emergency surgery, with simultaneous intraoperative neck incision and replacement of the unilateral or bilateral carotid arteries. Among them, there were 19 males with a mean age of(49.57±2.14)years old. Preoperative brain CT indicated abnormalities in 15 cases, transient neurological dysfunction occurred in 5 cases, and syncope in 1 case.Results:Procedures included ascending aorta replacement in 10 cases, Bentall procedure in 18 cases, and Wheat procedure in 1 case. Arch operations involved partial arch replacement in 3 cases and Sun’s procedure in 26 cases. Simple left carotid artery replacement was performed in 6 cases, simple right carotid artery replacement in 19 cases, and bilateral carotid artery replacement in 4 cases. Cerebral protection measures during circulatory arrest included unilateral cerebral perfusion in 24 cases and bilateral cerebral perfusion in 5 cases. The mean operation time was(7. 6±0. 3) h, with a mean cardiopulmonary bypass time of(196. 3±8. 7) min, aortic cross-clamp time of(113.2±6.4) min, ischemic time 12(5-16.5) min, and lowest temperature of(26.3±0.4)°C. One patient experienced in-hospital mortality. Postoperatively, new neurological dysfunction occurred in 2 cases, including 1 case with coma and permanent neurological deficit.Conclusion:In patients with acute type A aortic dissection involving severe stenosis or occlusion of the carotid arteries, simultaneous carotid artery replacement via neck incision during aortic surgery is a safe and reliable surgical approach.

Objective:To evaluate the safety and efficacy of the neoadventitia technique for root repair in acute type A aortic dissection(ATAAD).Methods:From January 2019 to February 2022, a total of 94 patients with ATAAD who underwent surgical treatment in Beijing Anzhen Hospital were retrospectively analyzed. According to the different treatment methods for the aortic root, the patients were divided into the neoadventitia technique group(58 cases) and the Bentall group(36 cases). The perioperative data and postoperative follow-up results of the two groups were compared, and the efficacy of the new adventitia technique in acute type A aortic dissection was analyzed.Results:There were no intraoperative deaths. The 30-day mortality was 3.4% and 5.6% in the neoadventitia group and Bentall group, respectively ( P=0.636). The cardiopulmonary bypass time[(154.3±29.8)min, P<0.001] and aortic clamp time[(94.7±20.6)min, P<0.001)]were significantly shorter in the neoadventitia group, compared with the Bentall group. Aortic regurgitation was significantly improved after the operation (0.33±0.50 vs. 1.02±0.80, P<0.001). No aortic root-related secondary intervention occurred during follow-up. There was no significant difference in mortality between the two groups( P=0.248). Conclusion:Neoadventitia root repair is a safe and feasible method for the treatment of ATAAD, which has good short-term and mid-term efficacy.

Objective:To summarize our experience and outcomes of surgical repair of type Ⅱ right-sided aortic arch(RAA) with Kommerell's diverticulum(KD).Methods:From May 2010 to August 2020, a total of 13 patients with type Ⅱ RAA and KD underwent surgery at our center. Mean age was(50.46±10.31) years, 10 were male, and 3 were female. All patients had an aneurysmal KD and aberrant left subclavian artery(ALSA). Preoperative comorbidities included type B aortic dissection in 1 case, aortic arch pseudoaneurysm in 2 cases, and type B intramural hematoma in 2 cases, respectively. Eight(61.5%) patients underwent stented elephant trunk procedures under moderate hypothermic circulatory arrest combined with selective antegrade cerebral perfusion via median sternotomy, and all of them had ALSA reconstruction. Five(38.5%) patients underwent distal arch and descending thoracic aortic replacement through a right posterolateral thoracotomy, the ALSA was reconstructed or ligated in 1 each, and ALSA embolization was performed before surgery in the other 3 cases.Results:No operation deaths occurred. Recurrent laryngeal nerve injury occurred in 2 cases. There was 1(7.69%) in-hospital death. Follow-up was complete in 100 % at mean(5.28±3.84) years. No late death occurred. A persistent anastomotic leak of the proximal arch was detected in a patient who underwent stented elephant trunk procedure, but no aortic dilatation or tracheal and esophageal compression was observed during follow-up. Meanwhile, aortic events, limb ischemia, or symptoms of tracheal and esophageal compression were not observed in the remaining 11 patients.Conclusion:Surgical repair of type Ⅱ RAA with KD can achieve favorable early and midterm outcomes. Surgical strategies should be chosen based on the anatomy of the aorta and whether it is combined with compression symptoms.

Objective:To evaluate the efficacy of new arch-clamping technique in Sun’s procedure to repair acute type A aortic dissection.Methods:67 consecutive patients with acute type A aortic dissection who underwent total arch replacement and frozen elephant trunk implantation(TAR+ FET) from Dec 2019 to Dec 2022 with using new arch-clamping technique during operation. Relative intraoperative and postoperative variables and complications were compared.Results:Cardiopulmonary bypass time was(166.66±32.81)min, the aortic occlusion time was(100.49±19.96)min, the circulatory arrest time was(3.97±1.63)min, the lowest nasopharyngeal temperature was(25.716±1.304)℃, and the lowest bladder temperature was(26.209±1.552)℃. The whole group died in hospital in 2 cases(2.98%), cerebral infarction in 3 cases(4.48%), transient neurological dysfunction in 4 cases(5.97%), paraplegia patients in 1 case(1.49%), renal failure requiring continuous dialysis in 4 cases(5.97%).Conclusion:New arch-clamping technique decrease postoperative complication, and is a safe and feasible innovative approach to effectively improve surgical outcome of Sun’s procedure for repair of acute type A aortic dissection.

Aortic aneurysm (AA) is a vascular disease involving the progressive dilation of aorta diameter. It is usually asymptomatic but with high mortality once rupture. Currently, there is no effective pharmacologic treatment. MicroRNA specifically refers to non-coding small RNAs consisting of 19-25 nucleotides. The characteristic of microRNA targeting multiple genes seems to form a complicated regulation network, which receives considerable attention. Emerging studies show that microRNAs are closely related to the occurrence and development of AA. Many microRNAs are involved in multiple cell processes and functions and may participate in the pathogenesis of AA, including endothelial cell dysfunction, inflammatory cell infiltration, smooth muscle cell apoptosis, and extracellular matrix degradation. This article will describe the animal models for AA research and the latest progression of microRNA and AA.

Objective:To analyze the long-term outcomes of hybrid arch repair(HAR) treating aortic arch pathologies.Methods:Between January 2009 and January 2018, 87 consecutive patients underwent HAR for aortic arch pathologies at Beijing Anzhen Hospital. 76 were males. 2 cases were in zone 0, 46 cases were in zone 1, and 39 cases were in zone 2. The zones of the aortic arch were defined following the Ishimaru classification.Results:Five(5.7%) operative death occurred. 13 patients(19.1%) died during the follow-up. The overall survival rate was 88.4%, 83.3%, 83.3%, 49.8% at 1, 3, 5, 10 year, respectively. Multivariate Cox proportional risk analysis showed that stroke( HR=20.626, 95% CI: 2.698-157.685, P=0.004) was an independent risk factor for short-term death. Stroke( HR=16.234, 95% CI: 4.103-64.229, P<0.001) and spinal cord infury( HR=11.060, 95% CI: 2.150-56.893, P=0.004) were independent risk factors for long-term death. Conclusion:In conclusion, HAR could be an alternative procedure for the patients that are not suitable for open repair under the premise of strict control of indications. In the future, the risk assessment system and uniform operational indications for HAR should be further established.

Objective:To study the risk factors of massive bleeding in patients with acute Stanford type A aortic dissection undergoing moderate hypothermic circulatory arrest repair.Methods:From January 2016 to October 2017, 486 consecutive patients with acute type A aortic dissection were included in the study. All operations were performed with moderate hypothermic circulatory arrest. The basic clinical data of patients were collected retrospectively. Massive bleeding was defined according to definition of Universal Definition of Perioperative Bleeding(UDPB) 4 class and the Blood Conservation Using Antifibrinolytics in a Randomized Trial(BART). Significant variables in univariate analysis were included in multivariate logistic regression analysis. Results:Thirty-four patients(7.00%) died in hospital. A total of one hundred and eighty-seven patients(38.48%) fulfilled criteria of the definition of BART massive bleeding. Forty-five patients(9.26%), 8 patients(1.65%), 114 patients(23.46%), 147 patients(30.25%) and 172 patients(35.39%) were in grade 0, grade 1, grade 2 and grade 4, respectively. With BART as the end point, the result of multivariate logistic regression showed that female gender( OR=3.32, P<0.001), anemia( OR=2.24, P=0.04), clearance creatine≤85 ml/min( OR=1.93, P=0.01), D-dimer level(every 500 ng/ml increase, OR=1.02, P=0.003), cardiopulmonary bypass(CPB) time( OR=1.01, P<0.001), total arch replacement(TAR, OR=2.40, P=0.02) were independent risk factors for massive bleeding, and the time from onset to operation( OR=0.86, P=0.01) was protective factor. With UDPB 4 class as the end point, multivariate logistic regression showed that creatinine clearance≤85 ml/min( OR=2.05, P=0.001), CPB time( OR=1.01, P=0.04) were independent risk factors for massive bleeding. The time from anset to operation( OR=0.85, P=0.002) and Bentall procedure( OR=0.65, P=0.04) were the protective factors. Conclusion:Massive bleeding was more common in acute Stanford type A aortic dissection. Female gender, poor preoperative renal function, high D-dimer level, early time accepting surgical operation and long CPB were independent risk factors. For high-risk patients, simple and effective surgical methods should be taken to reduce the risk of bleeding.

Objective:To summarize the surgical treatment strategy for aortic injury caused by trauma.Methods:From January 2009 to January 2018, 34 patients with TAI were treated in Beijing Anzhen Hospital. 10 had hypertension. 23 cases were males. There were 31 cases caused by traffic accidents, 2 cases were fall injuries, and 1 case was bruise. 9 cases were thoracic aortic pseudoaneurysm, 6 cases were thoracic aorta, and 19 cases were aortic dissection. 29 patients underwent TEVAR and 5 patients underwent OR (2 patients with type A aortic dissection undergoing Bentall + Sun's procedure, 1 patient with type B aortic dissection and 2 patients with thoracic aortic pseudoaneurysm undergoing stented elephant trunk procedure).Results:The follow-up time was (45.09±23.10) months. The mean age of patients undergoing OR or TEVAR was (44.80±20.57) years old, (45.93±11.01) years old; the mean operation time was(403.20±30.30) minutes, (105.72±27.76) minutes; the mean hospitalization (19.00±6.04), (5.76±3.08) days. There were no deaths in the two groups. 2 patients uundergoing TEVAR had left upper limb numbness.Conclusion:The treatment of patients with TAI should be based on the general condition, the classification of injury, the involving regions and anatomical features to choose different treatments. In addition, the long-term prognosis of patients remains to be determined.

The aortic dissection (AD) carries high mortality which increases by 1%-2% per hour after onset in untreated patients. Fifty percent of patients will die in 48 hours, and 70%-80% patients will die in 2 weeks without treatment. Moreover, acute AD during pregnancy is a rare and much catastrophic disease with high lethality for the mother and fetus simultaneously. At present, AD is so rare that most articles are mainly small cohort studies and case reports. Therefore, we reviewed literatures in order to provide clinical reference for the comprehensive treatment of AD.