Valve-sparing aortic root replacement is increasingly used in selected patients with acute aortic dissection and preserved valve anatomy. We present the case of a 52-year-old man with acute Stanford type A aortic dissection extending from the aortic root to the iliac bifurcation with arch involvement; this was complicated by severe aortic insufficiency and right lower extremity malperfusion. The patient underwent emergent valve-sparing root replacement using the David technique combined with zone 2 arch reconstruction under hypothermic circulatory arrest and selective antegrade cerebral perfusion. Intraoperative echocardiography confirmed excellent valve function with trace residual regurgitation. The postoperative course was notable for transient vasoplegia and re-exploration without bleeding, followed by uneventful recovery and discharge on postoperative day 11. This case highlights the feasibility of combining valve-sparing root replacement with zone 2 arch reconstruction in the acute setting of Stanford type A dissection with malperfusion, allowing restoration of true lumen flow while preserving native valve function.

Dysphagia lusoria is a rare cause of dysphagia resulting from extrinsic esophageal compression by an aberrant right subclavian artery (ARSA). Its coexistence with thyroid pathology may obscure the diagnosis and delay appropriate management. We report a case of a 29-year-old female who presented with a multinodular goiter and dysphagia disproportionate to the size of the thyroid swelling. Clinical evaluation, thyroid ultrasonography, and fine-needle aspiration cytology confirmed a benign euthyroid multinodular goiter. Owing to persistent dysphagia, further evaluation was undertaken. A barium swallow demonstrated extrinsic compression of the esophagus, while computed tomography aortogram confirmed an ARSA coursing posterior to the esophagus, establishing the diagnosis of dysphagia lusoria. The patient underwent total thyroidectomy for the multinodular goiter; however, her dysphagia persisted postoperatively. She was subsequently referred to the cardiothoracic vascular surgery team for definitive surgical management of the ARSA. This case highlights the importance of considering vascular anomalies in patients with dysphagia that is disproportionate to the degree of thyroid enlargement. Early recognition through appropriate imaging and a multidisciplinary approach are essential for accurate diagnosis, avoidance of unnecessary interventions, and optimal patient outcomes.

Vascular graft remodeling and aneurysm progression are commonly studied in small animal models, but non-terminal methods for their assessment remain limited. This study evaluated contrast-enhanced micro-CT as a tool for longitudinal, in vivo monitoring of vascular grafts in rodents. Using a transplant model in which a pulmonary artery segment was implanted into the recipient's abdominal aorta, creating a pulmonary vascular graft, we compared a molecular iodinated contrast agent with a nanoparticle-based agent. The molecular agent was rapidly cleared, resulting in insufficient vascular opacification for graft visualization or quantification. In contrast, the nanoparticle agent provided prolonged vascular enhancement, enabling high-resolution imaging and quantitative assessment of graft morphology and aneurysm development over time. These findings demonstrate that contrast-enhanced micro-CT, particularly using nanoparticulate blood-pool contrast agents, enables a longitudinal, non-terminal evaluation of vascular grafts in rodents, enabling quantitative monitoring of graft remodeling, overcoming the limitations of traditional post-mortem, single timepoint analyses.

Despite significant progress in revascularization techniques, the vascular approach itself can still be a challenge in complex polyvascular disease. In this case report, we describe the feasibility of a potentially underutilized alternative vascular approach in a patient with multiple arterial occlusions who presented to our hospital with acute multivessel thromboses and chronic occlusions of the distal aorta and subclavian arteries, which rendered noninvasive blood pressure measurements unreliable. The patient also exhibited signs of heart failure with a severely reduced ejection fraction, likely due to ongoing ischemia, as the ventricles had not yet remodeled. To overcome the anatomical limitations safely, we used superficial temporal artery access for coronary angiography - an approach first described, to the best of our knowledge, by Csavajda et al. In addition, this access enabled angiography of the aorta and its branches, visualization of collateral flow, and invasive intra-aortic blood pressure measurement. Together with the possibility to better titrate medical therapy, this additional diagnostic information allowed us to plan aortocoronary bypass surgery with appropriate graft selection and ultimately contributed to improved patient outcomes.Clinical Impact:In complex polyvascular patients with multiple arterial occlusions, when standard femoral and radial access sites are not feasible and peripheral blood pressure measurements are unreliable, an alternative vascular approach through the superficial temporal artery for coronary angiography, aortography, and invasive blood pressure measurement can be safely utilized to improve diagnostic accuracy, therapeutic planning, and clinical outcomes. This illustrative case highlights the usefulness and safety of this vascular approach and demonstrates additional technical possibilities that can be achieved through its use.

A residual false lumen after type A aortic dissection repair may rarely serve as an embolic route to the cerebral circulation. A woman in her 60s underwent ascending aortic replacement for Stanford type A aortic dissection, leaving a residual patent dissection involving the supra-aortic branches and the descending aorta. Despite receiving anticoagulant and antiplatelet therapies, the patient developed recurrent multifocal cerebral infarctions. Transesophageal echocardiography (TEE) demonstrated an entry tear in the descending aorta communicating from the true lumen to the false lumen. Flow became markedly stagnant toward the proximal false lumen, with thrombus-like echogenic material. Four-dimensional computed tomography (4DCT) confirmed delayed retrograde flow ascending within the false lumen toward the arch. Total arch replacement was performed to eliminate the suspected embolic route. Intraoperative findings confirmed thrombotic material within the false lumen. No recurrent cerebral infarctions were observed postoperatively.

A circumaortic renal vein is a congenital vascular anomaly involving an additional renal vein that traverses posterior to the aorta in addition to the normal renal vein traversing anterior to the aorta.[12] In aortic surgery, it is common to ligate the left renal vein (LRV) to aid in surgical exposure, which is typically inconsequential due to collateral venous channels. We report a case of a circumaortic LRV with the preaortic branch ligated during abdominal aortic aneurysm (AAA) surgery and, as a result, retroaortic LRV hypertrophy was observed during follow-up.

Iatrogenic arteriovenous (AV) fistula is a rare but treatable cause of high-output heart failure that can mimic restrictive cardiomyopathy and may lead to inappropriate listing for heart transplantation.

Ascending aortic aneurysm is a rare complication occurring after combined heart-lung transplants. Most post-transplant aortic pathologies are infective in origin and typically present as mycotic pseudoaneurysms or with features of aneurysmal rupture leading to hemodynamic instability. We report the case of a 13-year-old girl who underwent heart-lung transplantation 8 months back, presenting with a large unruptured ascending aortic aneurysm with stable hemodynamics. Surgical repair was performed using a collagen-coated polyester tube graft under cardiopulmonary bypass with peripheral femoral cannulation. The post-operative course was uneventful, and the patient was discharged in stable condition. Microbiological examination of the resected specimen showed no infective etiology, and histopathology analysis showed normal findings. The site of aortic anastomosis is a potential source of aneurysm. Discrepancy in tissue quality between the donor and recipient aorta can be responsible for compliance mismatch that causes a difference in wall tension, causing critical stress at the anastomosis. This case highlights the need for vigilant surveillance of the ascending aorta in transplant recipients irrespective of donor aorta, to allow timely detection and management of aneurysmal complications, and the need for screening of donor tissues for connective tissue disorder to monitor the recipient post-operatively.