Annals of cardiothoracic surgery最新文献

{"title":"Endovascular technology for aortic arch repair: from innovation to integration.","authors":"Foeke J H Nauta, Pim S van Sambeeck, Nabil Saouti, Sjoerd Jenniskens, Mark Dirven, Robin H Heijmen","doi":"10.21037/acs-2026-0141-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0141-aar","url":null,"abstract":"<p><p>Treatment of aortic arch pathology is one of the most challenging areas in cardiovascular surgery due to the complex anatomy and proximity to critical cerebral vessels. Open aortic arch replacement with cardiopulmonary bypass and deep hypothermic circulatory arrest remains the gold standard but can be associated with significant perioperative morbidity and mortality, particularly in elderly and comorbid patients. Over the past two decades, thoracic endovascular aortic repair (TEVAR) has become the gold standard for most descending aortic pathologies. As a result, TEVAR use has expanded into the aortic arch, facilitated by hybrid approaches that combine supra-aortic vessel debranching with endovascular stent-grafting. Following this approach, TEVAR, in combination with the use of chimney and snorkel grafts, was developed in an attempt to treat the aortic arch with a complete endovascular approach. However, these techniques have been associated with complications such as stent-graft occlusion, collapse, endoleaks, and strokes. Further developments have led to <i>in situ</i> laser fenestrations, and branched and fenestrated endografts, thus enabling total endovascular reconstruction. Contemporary series demonstrate high technical success with acceptable early outcomes in selected high-risk patients. In addition, an increasing experience has been reported with hybrid approaches to the aortic arch, often involving a zone 2 arch replacement followed by completion TEVAR when indicated. While hybrid and endovascular strategies expand the therapeutic armamentarium, careful patient selection, meticulous procedural planning, and preservation of cerebral and spinal perfusion are paramount to minimizing neurological complications. Emerging device technologies, including off-the-shelf branched systems and modular delivery platforms, along with advanced imaging and computational planning, continue to improve procedural safety and feasibility. Lastly, the impact of stiff stent-grafts on the cardiovascular system is largely unknown but raises concerns, as it diminishes the Windkessel function of the proximal aorta. This appears to lead to increased left ventricular afterload, new-onset hypertension, adverse cardiac remodeling, and increased strain in adjacent aortic segments. This keynote lecture reviews the evolution of endovascular technology for aortic arch repair from innovation to integration, discusses current treatment strategies, and highlights future directions that may further optimize endovascular therapy in modern aortic practice.</p>","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"45"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13470926/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The aortic window: a temporal framework for acute type A aortic dissection.","authors":"Farhin Holia, Aung Ye Oo, Colin D Bicknell, Thanos Athanasiou, Catherine Fowler, Christoph A Nienaber, Graham Cooper, Eva Göncz, John A Elefteriades, Hans-Joachim Schäfers","doi":"10.21037/acs-2026-0253-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0253-aar","url":null,"abstract":"<p><strong>Background: </strong>Acute type A aortic dissection (ATAAD) is a surgical emergency with time-dependent mortality. Surgical outcomes in high-volume centers are excellent, yet population-level outcomes remain catastrophic. This gap reflects a systems failure in recognition, diagnosis, and coordination rather than surgical inadequacy, and no formal time-based pathway currently governs care from emergency presentation to surgery.</p><p><strong>Methods: </strong>Current epidemiology, international guidelines, registry evidence, and national audit data were synthesized, together with the structure of established time-critical pathways in ST-elevation myocardial infarction, stroke, major trauma, and sepsis, and multidisciplinary and patient-and-public input, to derive a temporal framework for ATAAD. The framework is advanced as a hypothesis for formal international consensus validation rather than an empirically validated standard.</p><p><strong>Results: </strong>The proposed framework, the aortic window, is a phased pathway from emergency-department (ED) arrival to first surgical incision, structured as RACE (four acute phases: REACH, ALERT, CONVEY, ESCALATE) and RESTORE (recovery and lifelong surveillance), and operationalized through a named activation protocol. ED-to-incision time is the principal whole-system endpoint, chosen because it captures pre-diagnosis delay that diagnosis-anchored metrics exclude. Process and outcome measures are defined at case level with scheduled network review, aligned to established national audit registries. Implementation is staged and incorporates an education and run-in period before performance assessment.</p><p><strong>Conclusions: </strong>The aortic window reframes ATAAD as a system-level, time-critical emergency amenable to the organizational solutions that improved outcomes in other time-dependent conditions. The proposed targets require prospective evaluation but provide a structured, measurable basis for coordinated pathway improvement.</p>","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"49"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13471113/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148758263","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cerebral protection strategies in aortic arch surgery: a review of techniques and outcomes.","authors":"Alessandro Leone, Antonio Piperata, Benedetta Guerrini, Ivan Tammaro, Filippo Londi, Ludovica Fabiani, Davide Pacini, Luca Di Marco","doi":"10.21037/acs-2026-0201-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0201-aar","url":null,"abstract":"<p><strong>Background: </strong>Cerebral protection is a key determinant of perioperative outcomes in aortic arch surgery. Despite significant advances, optimal strategies regarding temperature, perfusion modality, and cannulation site remain controversial, with heterogeneous evidence and lack of standardized protocols.</p><p><strong>Methods: </strong>This narrative review summarizes experimental and clinical evidence from the last 15 years, focusing on the main determinants of cerebral protection: cerebral blood flow (CBF), autoregulation, perfusion pressure, temperature management, cannulation strategies, and antegrade (ACP) versus retrograde cerebral perfusion (RCP).</p><p><strong>Results: </strong>Available evidence consistently shows that any form of cerebral perfusion is superior to no perfusion during circulatory arrest (CA). Selective antegrade cerebral perfusion (SACP) has progressively emerged as the most widely adopted strategy worldwide, supported by its more physiological flow pattern and encouraging clinical outcomes. Axillary artery cannulation is currently the preferred approach and is associated with a lower stroke risk compared to femoral access, although femoral cannulation remains a valid alternative in unstable patients requiring rapid cardiopulmonary bypass (CPB) initiation. Comparative studies between ACP and RCP demonstrate no clear superiority in terms of mortality or permanent neurological dysfunction (PND), particularly for short CA times. However, SACP may reduce temporary neurological deficits (TNDs). A global shift towards moderate-to-mild hypothermia combined with cerebral perfusion has been observed, with favorable outcomes. Nonetheless, substantial variability persists in perfusion parameters, including flow, pressure, and the choice between unilateral and bilateral cerebral perfusion.</p><p><strong>Conclusions: </strong>Contemporary practice is moving toward strategies that better replicate physiological cerebral perfusion, favoring antegrade flow with moderate hypothermia. However, the lack of high-quality randomized evidence and persistent heterogeneity limit definitive recommendations, highlighting the need for standardized protocols and individualized approaches.</p>","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"52"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13471129/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757210","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Should open and endovascular arch repair coexist or compete?","authors":"Maximilian Luehr, Ajay Moza, Christian Uhl, Alexander Gombert","doi":"10.21037/acs-2026-0218-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0218-aar","url":null,"abstract":"","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"54"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13471120/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757709","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Standardized total arch replacement using the frozen elephant trunk technique.","authors":"Davide Pacini, Giacomo Murana, Silvia Snaidero, Chiara Nocera, Alessandro Leone, Antonio Piperata, Carlo Mariani, Luca Di Marco","doi":"10.21037/acs-2026-0139-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0139-aar","url":null,"abstract":"","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"59"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13470924/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148763126","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"New type A arch dissection stent: restoration of supra-aortic vessel perfusion.","authors":"Leonard Pitts, Matteo Montagner, Markus Kofler, Gaik Nersesian, Julius Kaemmel, Volkmar Falk, Semih Buz, Jörg Kempfert","doi":"10.21037/acs-2026-0136-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0136-aar","url":null,"abstract":"","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"58"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13471117/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757332","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Aortic arch in the shaggy aorta: challenges and solutions.","authors":"Joon Chul Jung, Jae Hang Lee, Kay-Hyun Park","doi":"10.21037/acs-2026-0070-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0070-aar","url":null,"abstract":"","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"60"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13470919/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Innominate artery reimplantation as a strategic step in lifetime aortic management: a vascular surgeon's perspective.","authors":"Vincenzo Vento, Paolo Berretta, Erlil Mali, Michele Galeazzi, Marco Di Eusanio, Emanuele Gatta","doi":"10.21037/acs-2026-0268-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0268-aar","url":null,"abstract":"<p><p>The management of complex aortic disease has evolved toward a \"lifetime management\" strategy, where the initial surgical arch repair critically influences the feasibility of future staged interventions. While the left subclavian artery has received significant attention, the strategic role of the innominate artery (IA) as a primary endovascular gateway remains underappreciated. This paper explores how IA reimplantation geometry determines the success of subsequent endovascular procedures. We analyzed the technical requirements for optimal antegrade endovascular access during complex downstream repairs, such as branched and fenestrated endovascular aortic repair (B-FEVAR). Two surgical strategies aimed at optimizing supra-aortic vessel alignment were evaluated: the \"arch vessels' switch\" technique using a standard trifurcated graft, and the use of the novel T-NEXT hybrid prosthesis (Terumo Aortic, Vascutek Ltd., Renfrewshire, UK). In currently available frozen elephant trunk (FET) and hybrid arch grafts, the longitudinal arrangement of supra-aortic branches often results in sequential vessel reimplantation patterns that may create acute angulations between the IA and the ascending aorta. Such configurations can impair guidewire and catheter maneuverability, reducing effective transmission of torque and forward force during antegrade navigation toward the descending thoracic and thoracoabdominal aorta. The \"arch vessels' switch\" technique, in which the IA is reimplanted onto the distal (3^rd) branch of a standard trifurcated graft, improves coaxial alignment and creates a smoother, more anteriorly directed trajectory for catheters and delivery systems intended for downstream aortic interventions. Similarly, the T-NEXT hybrid prosthesis (Terumo Aortic, Vascutek Ltd.) combines preservation of a longer native ascending aortic segment, potentially facilitating future root or ascending aortic reinterventions with a dedicated transverse 10-mm IA branch that provides a stable and pre-aligned access route. This optimized geometry minimizes abrupt directional changes at the anastomotic level, facilitates device advancement, and enhances support for guidewires, sheaths, and endovascular adjuncts. IA reimplantation should be conceptualized as a strategic maneuver rather than a purely reconstructive step. A multidisciplinary \"aortic team\" approach is essential to design arch reconstructions that facilitate bidirectional endovascular navigation. By optimizing IA take-off geometry, surgeons can prevent \"dead-end\" anatomies and ensure that the primary arch repair serves as a durable platform for the patient's entire therapeutic journey.</p>","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"47"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13470912/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757365","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of the aortic arch in acute non-A non-B aortic dissection.","authors":"Davut Cekmecelioglu, Zeynep Bengi Eren, Rana Afifi, Ourania Preventza","doi":"10.21037/acs-2026-0213-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0213-aar","url":null,"abstract":"","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"56"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13470922/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148759578","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Aortic arch open surgery: countdown started or timeless approach?","authors":"Luca Di Marco, Roberto Di Bartolomeo","doi":"10.21037/acs-2026-0204-aar","DOIUrl":"https://doi.org/10.21037/acs-2026-0204-aar","url":null,"abstract":"","PeriodicalId":8067,"journal":{"name":"Annals of cardiothoracic surgery","volume":"15 4","pages":"55"},"PeriodicalIF":4.1,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13471119/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757385","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}