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25 26Objective: Floating aortic thrombus is an under-recognised source of systemic emboli 27 and carries a life-threatening risk of stroke when located in the aortic arch. Optimal 28 treatment is not established in available guidelines. We report our experience in 29 managing floating thrombi in the aortic arch. were identified. Eight patients presented with a symptomatic embolic event while two 37 patients were asymptomatic. One patient presenting with stroke due to embolic 38 occlusion of all supra-aortic vessels died two days following admission. Three patients 39 (two asymptomatic and one unfit for surgery) were treated conservatively by 40 anticoagulation, leading to thrombus resolution in two patients. In the third patient, the 41 thrombus persisted despite anticoagulation, resulting in recurrent embolic events. 42The remaining six patients underwent open thrombectomy of the aortic arch during 43 deep hypothermic circulatory arrest. All patients treated by surgery had an uneventful 44 postoperative course with no recurrent thrombus or embolic event during follow-up. 45Median follow-up of all patients was 17 months (range 11 -89 months). 46

Retrograde access for complex aortic endografts with antegrade branches using a steerable sheath appears feasible and effective and may serve as an alternative to upper extremity access.

Surgical treatment of native and aortic graft or endograft infection remains high risk. Self made bovine pericardial tube grafts for in situ reconstruction are a promising option offering many advantages. Despite high early mortality rates, early radiological and mid-term clinical results are good. Definitive eradication of the infection seems feasible after in situ insertion of xeno-pericardial material for aortic repair.

Late aorta related mortality in IMH was low whereas all-cause mortality was substantial. Aorta related mortality in IMH patients only occurs during the first year after diagnosis. Interventions after the first year are rarely necessary.

During the last 20 years, a clear shift has been observed towards thoracic endovascular aortic repair for different aortic pathologies. However, total endovascular repair of the aortic arch remains technically demanding. Simultaneous perfusion of all supra-aortic arteries without longer cerebral ischemia time, whilst trying to avoid cerebral embolization, labels endovascular aortic arch repair with highest level of technical difficulty and surgical expertise. The aim of this article is to present an overview of the current technical options for endovascular aortic arch repair and their early results. Currently, early results are reported from four endovascular arch replacement techniques: hybrid repair, total endovascular approach, chimney grafts and in-situ fenestration. The early results of these different arch replacement techniques are promising, especially the total arch replacement with custom-made fenestrated or branched stent-grafts. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.

To investigate the influence of flushing thoracic stent-grafts with carbon dioxide and perfluorocarbon on the amount of gas released during stent-graft deployment in thoracic endovascular aortic repair (TEVAR). Materials and Methods: Ten TX2 ProForm thoracic stent-grafts were deployed into a water-filled container with a curved plastic pipe and flushed sequentially with carbon dioxide, 20 mL of liquid perfluorocarbon (PFC), and 60 mL of saline. Released gas was measured using a calibrated setup. The volume of released gas was compared with the results of an earlier published reference group, in which identical stent-grafts were flushed with 60 mL saline alone as recommended in the instructions for use. Results: The average amount of gas released in the test group was 0.076 mL, significantly lower (p<0.001) than the mean 0.79 mL of gas released in the reference group. Big bubbles appearing at the tip of the sheath when deployment was started were seen in all grafts of the reference group but in only 2 of the test group stent-grafts. Small bubbles were less frequent in the test group. Conclusion: The amount of gas released from thoracic stent-grafts during deployment can be influenced by different flushing techniques. The use of PFC in addition to the carbon dioxide flushing technique reduces the volume of gas released during deployment of tubular thoracic stent-grafts to a few microliters. This significant effect is presumably based on the high solubility of carbon dioxide in perfluorocarbon and could be a potential future approach to lower the risk of cerebral injury and stroke from air embolism during TEVAR.

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