\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Ascyrus Medical Dissection Stent In the treatment of acute type A Aortic
dissection. A First-Hand Experience}



\author[1]{Mouhammad Kanj}%
\author[2]{Benoit Cosset}%
\author[2]{Alexandre Oliny}%
\author[2]{Fadi Farhat}%
\affil[1]{Department of Cardiothoracic Surgery Faculty of Medical Science Lebanese University Beirut Lebanon}%
\affil[2]{Hopital Cardio-vasculaire et Pneumologique Louis Pradel}%


\vspace{-1em}



  
  \date{May 22, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
\textbf{Background:} Acute type A aortic dissection is associated with a
significant perioperative morbidity and mortality. Ascyrus Medical
Dissection Stent (AMDS) is a novel bare stent graft developed to be used
as an adjunct to standard surgical approach to promote true lumen
expansion and therefor enhance aortic remodeling. \textbf{Patients and
Methods:} From March 2021 to March 2022, four consecutive patients who
presented with acute Debakey type I aortic dissection underwent emergent
surgical repair with an inclusion (David) procedure and implantation of
an AMDS. We analysed patient's files prospectively and described the
perioperative outcomes. \textbf{Results:} All four device implantations
were successful. Overall 30-day mortality was 0 \%. Malperfusion that
was present in two patients pre-operatively improved after AMDS
implantation. At follow up, no aortic reinterventions were needed. No
aortic injury related to the device was noted. Favourable changes in
aortic true lumen and false lumen dimensions were found in most of our
patients but the AMDS was compressed at the isthmus in one patient.
\textbf{Conclusion:} AMDS is a reliable and secure device. However, its
benefits remain unclear when it comes to a positive remodeling and seems
less likelihood comparable to a frozen elephant trunk. The main reason
seems to be an insufficient radial force of the AMDS.%
\end{abstract}%



\sloppy


\textbf{Ascyrus Medical Dissection Stent In the treatment of acute type
A Aortic dissection. A First-Hand Experience}

Mouhammad Kanj, MD\textsuperscript{1,2}, Benoit Cosset,
MD\textsuperscript{2}, Alexandre Oliny, MD\textsuperscript{2}, Fadi
Farhat, MD,PhD\textsuperscript{2}. 1) Department of Cardiothoracic
Surgery, Faculty of Medical Science, Lebanese University, Beirut,
Lebanon. 2) Department of Cardiovascular Surgery, Louis Pradel Hospital,
Lyon, France.\textbf{Conflict of interest:} none
declared.\textbf{Funding:} none.\textbf{Word Count:} 1920.\textbf{Data
availability Statement}: The data that support the findings of this
study are available from the corresponding author upon reasonable
request.\textbf{Consent statement:} Not applicable.\textbf{Corresponding
Author: Pr} Fadi Farhat\textbf{Infirmerie Protestante}1-3 Chemin de
Penthod 69300 Caluire-et-Cuire, France Tel +33 4 26 10 17 61 Fax + 33 4
72 00 74 92 E-mail
:\emph{fadi.farhat@infirmerie-protestante.com}\textbf{}

\textbf{Abstract:}

\textbf{Background:} Acute type A aortic dissection is associated with a
significant perioperative morbidity and mortality. Ascyrus Medical
Dissection Stent (AMDS) is a novel bare stent graft developed to be used
as an adjunct to standard surgical approach to promote true lumen
expansion and therefor enhance aortic remodeling.

\textbf{Patients and Methods:} From March 2021 to March 2022, four
consecutive patients who presented with acute Debakey type I aortic
dissection underwent emergent surgical repair with an inclusion (David)
procedure and implantation of an AMDS. We analysed patient's files
prospectively and described the perioperative outcomes.

\textbf{Results:} All four device implantations were successful. Overall
30-day mortality was 0 \%. Malperfusion that was present in two patients
pre-operatively improved after AMDS implantation. At follow up, no
aortic reinterventions were needed. No aortic injury related to the
device was noted. Favourable changes in aortic true lumen and false
lumen dimensions were found in most of our patients but the AMDS was
compressed at the isthmus in one patient.

\textbf{Conclusion:} AMDS is a reliable and secure device. However, its
benefits remain unclear when it comes to a positive remodeling and seems
less likelihood comparable to a frozen elephant trunk. The main reason
seems to be an insufficient radial force of the AMDS.

\textbf{Key Words:} Acute Aortic Dissection, AMDS, Remodeling

\emph{} \textbf{Introduction:}

Acute Debakey type I aortic dissection is a debilitating disease that
may be complicated by organ malperfusion in 30\% to 40\% and carries a
high mortality rate\textsuperscript{1-3}. The standard surgical repair
by hemiarch or arch reconstruction using an open distal anastomosis
successfully manages the primary entry tear by resection; however, the
distal false lumen may remain perfused and subsequently pressurized and
the true lumen yet incompletely expanded. This may result in ineffective
treatment of malperfusion and over time by a growth of the aortic
diameter leading to repeated interventions, mainly on the descending
aorta.

The Ascyrus Medical Dissection Stent (AMDS, Artivion, Kennesaw, USA) is
a new device developed to be used in adjunct to current surgical aortic
dissection repair and is designed to improve short-term malperfusion
syndrome and supposed to lessen long-term aneurysmal evolution.

This hybrid prosthesis is composed of proximal PTFE felt sutureg line
attached to an uncovered Nitinol wire braided stent (figure1). Bozso et
al. have shown on the DARTS trial the security and feasibility of the
AMDS implantation, and the capacity of this device to improve aortic
remodeling\textsuperscript{4,5}. Mehdiani et al. also showed that AMDS
can be safely performed in patients who need partial replacement of the
aortic arch beyond zone 0\textsuperscript{6}. We report the first French
implantation of the AMDS.

\textbf{Patients and Methods:}

\textbf{1.Patients Characteristics and Data Collection:}

During a 1-year period (March 2021 through March 2022), four consecutive
patients received the AMDS hybrid prosthesis at the decision of the same
attending surgeon for treatment of type I Debakey aortic dissections.
Demographic data, comorbidities, operative procedures and post-operative
variables were analyzed prospectively. Baseline characteristics of the
study population are summarized in table 1.

\textbf{2.Operative Technique:}

A re-implantation technique (David V) was performed in all patients. All
patients underwent emergency surgery with CPB initiated with arterial
cannulation via the right axillary artery and venous cannulation of the
right atrium, then general cooling was started. The ascending aorta was
cross clamped and myocardial protection was ensured through antegrade
cold crystalloid cardioplegia followed by intermittent administration of
selective coronary cardioplegia throughout the clamping time. Resection
of the aortic root leaving 3 to 4 mm of aortic remnants above the aortic
valve annulus was done systematically. Six sub-annular U stiches were
placed and anchored to a Valsalva Dacron tube (28-30mm diameter). The
aortic valve commissures were attached within the Valsalva Dacron tube.

At a rectal temperature of 28 \selectlanguage{ngerman}°C, and with cerebral monitoring by NIRS,
hypothermic peripheral circulatory arrest was started. Cerebral
perfusion was ensured by blood injection (7.5 to 10 ml/kg/min) into the
right subclavian artery and by clamping the origin of the
Brachiocephalic artery and the Left Common Carotid artery. Exploration
of the aortic arch demonstrated no supplementary entry tears in any
patient. Transection of the aorta was performed 1 cm proximal to the
origin of the Innominate trunk. A 55-55 mm uncovered AMDS was
systematically used and deployed over a guidewire in the true lumen of
the descending aorta. Anastomosis between the aorta and the AMDS collar
was performed with a addition of a Dacron tube and reinforced by an
external Teflon felt. General cardiopulmonary bypass was then
re-initiated for rewarming after the aortic arch was purged and the
Dacron tube clamped .

During rewarming time, re-implantation of the aortic remanents into the
valsalva Dacron tube with running 4.0 Polypropylene sutures then
re-implantation of the coronary ostia were performed. In one patient,
the dissection reached the coronary right ostium needing repair. End to
end anastomosis between the two Dacron tubes was done using before
declamping and CPB was weaned in a standard manner withour inotropic
support in any patient.

\textbf{3.Statistical analysis:}

Statistical analysis and graphics were done using statistical software
(IBM® SPSS® Statistics version 26.0; GraphPad Prism® version 8.0).

\textbf{Results:}

\textbf{1.Baseline Characteristics:}

The baseline clinical characteristics are presented in table 1. Mean age
was 61(+/-8) years old

and 3 patients were male (75\%). One patient had Marfanoid habitus. All
patients had a previous medical history of hypertension. Mean
Euroscore-II was 22(+/-18) \%. CT-Angiography was done pre-operatively
then on post-operative day 1 and 30 for all patients (figure 2). Primary
tear was identified in the ascending aorta in all patients. Two patients
(50\%) had evidence of dynamic intestinal malperfusion by compression of
the true lumen. One of those patients had also evidence of coronary
malperfusion and severe aortic insufficiency. Another patient had
preoperative acute neurological deficit marked with aphasia and
decreased consciousness.

\textbf{2.Operative Data:}

A re-implantation technique (David V) was performed in all patients
along with implantation of the AMDS. Surgical and perioperative data are
presented in table 2. The mean cross clamping time, cerebral perfusion
time and cardiopulmonary bypass time were respectively 85(+/-6),
15(+/-2) and 113(+/-8) min. Circulatory arrest was attempted at a body
core temperature of 28°C.

\textbf{3.Postoperative outcomes:}

Mortality and serious adverse events are summarized in table 3. One
patient had smooth postoperative course without complications. The
patient who had severe aortic insufficiency with coronary and intestinal
malperfusion developed right ventricular dysfunction and required
hemodyalisis post-operatively. He also developed right brachial plexus
palsy with full recovery and totally relieved from intestinal
malperfusion. The other patient with intestinal malperfusion developed
hemorrhagic shock post-operatively with severe abdominal pain. An
exploratory laparotomy revealed a huge hemoperitoneum that was drained.
The patient who had neurological deficit developed multiple small
cerebral emboli due to atrial fibrillation. He also developed
ventilator-associated pneumonia and acute renal insufficiency requiring
hemodialysis. His consciousness improved with time. No aortic
reinterventions were needed. No aortic injury related to the device was
noted. Mortality rate was zero at the post-operative day 30. Patients
were discharged from the hospital after an average of 21 days.

\textbf{4.Comparison of CT measurements:}

Figure 3 shows comparison of CT measurements of the different aortic
diameters.

The mean total aortic diameter remained stable at the aortic arch and
descending thoracic aorta in all patients. It increased at the isthmus
in one patient (by 31\%). The false lumen was obliterated at the aortic
arch in three patients and decreased in size (by 60\%) in the fourth
one. At the level of the isthmus it increased in only one patient
because of reperfusion. However, at the level of the descending thoracic
aorta, the mean false lumen size decreased in all patients (by 43\%).
Regarding the mean true lumen size, it increased in all patients (by
91\%) compared with baseline. However, the stent was compressed in one
patient at the level of the isthmus (figure 4). No distal anastomosis
re-entry tear was observed. A new entry tear was identified in one
patient at the level of abdominal aorta far below the distal AMDS tip.

\textbf{Discussion}

Even if the surgery of an acute Debakey type I aortic dissection is
performed with an open distal anastomosis and is mostlikely managed by a
hemiarch aortic reconstruction, this approach has a main disadvantage,
that is to leave entry tears in the proximal descending thoracic aorta
leading to false lumen patency in some patients, increasing the need for
re-operation\textsuperscript{7-10}. Total arch replacement with Frozen
Elephant Trunk allows for distal extension of a stent graft implant into
the true lumen of the descending aorta excluding re-entry tears in the
arch and proximal descending thoracic aorta. In the setting of acute
aortic dissection and deeply ill patients, this approach can increase
the CPB and circulatory arrest times, and exposes patients to additional
risks of paralysis, stroke and haemorrhage\textsuperscript{11,12}. It
may be more useful in particular situations in the setting of aortic
dissection like when there is arch aneurysm, or there is an entry tear
within the arch or in the proximal descending thoracic aorta associated
with the dissection\textsuperscript{13}.

Between these two approaches, the AMDS represents a novel hybrid
solution providing long thoracic coverage alleviating malperfusion and
excluding entry tears without significantly increasing the complexity of
surgery\textsuperscript{4-6}.

DARTS trial has shown a good rate of aortic remodeling. However, this
was a composite criterion; positive remodeling was defined on evidence
of false lumen obliteration, complete false lumen thrombosis and
favourable changes in aortic dimensions\textsuperscript{14,15}. Our
real-life experience shows that these results are more the consequence
of lumen's diameters correction than a complete false lumen thrombosis,
being possibly due to the primary entry tear exclusion. There was no
need for a redo surgery in our four patients, but we think that the
presence of Nitinol in the arch could jeopardize a second procedure at
this level.

In the two patients having intestinal malperfusion we noticed clinical
improvement. One of them remains having intestinal angina due to
dissection of the superior mesenteric artery. Favourable changes in
aortic true lumen and false lumen dimensions were found in most of our
patients but the AMDS was compressed at the isthmus in one of them. We
did not have any mortality in our patients. This shows that AMDS is a
reliable and secure device. However, its benefits remain unclear when it
comes to a positive remodeling and seems less likelihood comparable to a
frozen elephant trunk. The main reason seems to be an insufficient
radial force of the AMDS, which tend to lengthen rather to expand.

Many studies addressing the radial force of endovascular stents
emphasized on the importance of understanding radial force when
selecting a stent for every patient. Radial force of endovascular stents
provides effective support for blood vessels, maintains adequate lumen
patency, and secures fixation to artery wall\textsuperscript{16}. It
varies among stent designs, and differences depend on the type of
stents, the site of deployment or layer characteristics of each
stent\textsuperscript{17,18}. In vivo, endovascular stents would be
affected by the vessel curvature, blood pressure, vascular smooth
muscles characteristics and much more dynamic
factors\textsuperscript{17}. Surgeons should evaluate the possibility of
stent deformities during and after surgery\textsuperscript{19}. It is
believed that treatment of dissection with endovascular stent requires
fewer radial force compared with the treatment of aneurysm because too
much radial force at distal ends may lead to new entry tears. However,
the arch geometry for thoracic aorta requires larger radial forces to
seal\textsuperscript{20}. In its initial experience on AMDS stent,
Montagner et al. concluded that the low radial force of AMDS stent is
intended just to readapt the intima against the media and adventitia and
it is the subsequent expansion of the true lumen that will drive the
resolution of malperfusion\textsuperscript{21}. Furthermore, they
emphasized on the importance of low radial force of the AMDS stent which
can unlikely damage the intima. They also reported three failures of
device deployment, one of them being due to high turtosity of the aorta
causing kinking and incomplete AMDS expansion\textsuperscript{22}.

Eventhough we observed improvement of malperfusion, this may be
attributed only to primary entry tear resection. Actually, the radial
force of the AMDS is not adequate to guarantee distal expansion of the
true lumen, especially in case of visceral malperfusion and this was
seen in one of our patients. AMDS implantation should be avoided in
patients with aortic calcifications or kinking to prevent incomplete
stent expansion.

Another feature should be mentioned is that the AMDS is an uncovered
stent. In this condition, any entry tear not excluded by this bare stent
will remain active. This is why, we should absolutely avoid AMDS
implantation in patients with any primary entry tear in the

aortic arch.

The main limitations of this study remain in its small sample size, its
retrospective design and the absence of long-term follow-up.

\textbf{Conclusion}

This initial study suggests that the AMDS is safe, feasible and
reproducible adjunct to the standard surgical repair for acute Debakey
type I aortic dissection without extending the procedure time. However,
its benefits remain unclear when it comes to a positive remodeling.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Hagan PG, Nienaber CA, Isselbacher EM, et al. The International
  Registry of Acute Aortic Dissection (IRAD). \emph{JAMA} .
  2000;283(7):897.
\item
  Conzelmann LO, Weigang E, Mehlhorn U, et al. Mortality in patients
  with acute aortic dissection type A: analysis of pre- and
  intraoperative risk factors from the German Registry for Acute Aortic
  Dissection Type A (GERAADA). \emph{Eur J Cardio-Thoracic Surg} .
  2016;49(2):e44\selectlanguage{english}-e52.
\item
  Berretta P, Patel HJ, Gleason TG, et al. IRAD experience on surgical
  type A acute dissection patients: results and predictors of
  mortality.\emph{Ann Cardiothorac Surg} . 2016;5(4):346\selectlanguage{english}-351.
\item
  Bozso SJ, Nagendran J, MacArthur RGG, et al. Dissected Aorta Repair
  Through Stent Implantation trial: Canadian results. \emph{J Thorac
  Cardiovasc Surg} . 2019;157(5):1763\selectlanguage{english}-1771.
\item
  Bozso SJ, Nagendran J, Chu MWA, et al. Midterm Outcomes of the
  Dissected Aorta Repair Through Stent Implantation Trial. \emph{Ann
  Thorac Surg} . 2021;111(2):463\selectlanguage{english}-470.
\item
  Mehdiani A, Sugimura Y, Wollgarten L, et al. Early Results of a Novel
  Hybrid Prosthesis for Treatment of Acute Aortic Dissection Type A With
  Distal Anastomosis Line Beyond Aortic Arch Zone Zero. \emph{Front
  Cardiovasc Med} . 2022;9.
\item
  Moore NR, Parry AJ, Trottman-Dickenson B, Pillai R, Westaby S. Fate of
  the native aorta after repair of acute type A dissection: a magnetic
  resonance imaging study. \emph{Heart} . 1996;75(1):62\selectlanguage{english}-66.
\item
  Sultan I, Wallen TJ, Habertheuer A, et al. Concomitant antegrade stent
  grafting of the descending thoracic aorta during transverse hemiarch
  reconstruction for acute DeBakey I aortic dissection repair improves
  aortic remodeling. \emph{J Card Surg} . 2017;32(9):581\selectlanguage{english}-592.
\item
  Park K-H, Lim C, Choi JH, et al. Midterm Change of Descending Aortic
  False Lumen After Repair of Acute Type I Dissection. \emph{Ann Thorac
  Surg} . 2009;87(1):103\selectlanguage{english}-108.
\item
  Fattori R, Bacchi-Reggiani L, Bertaccini P, et al. Evolution of aortic
  dissection after surgical repair. \emph{Am J Cardiol} .
  2000;86(8):868\selectlanguage{english}-872.
\item
  Bozso SJ, White A, Nagendran J, Moon MC, Chu MWA. Hybrid aortic arch
  and frozen elephant trunk reconstruction: bridging the gap between
  conventional and total endovascular arch repair. \emph{Expert Rev
  Cardiovasc Ther} . 2018;16(3):209\selectlanguage{english}-217.
\item
  Shrestha M, Bachet J, Bavaria J, et al. Current status and
  recommendations for use of the frozen elephant trunk technique: a
  position paper by the Vascular Domain of EACTS. \emph{Eur J
  Cardio-Thoracic Surg} . 2015;47(5):759\selectlanguage{english}-769.
\item
  Shrestha M, Martens A, Kaufeld T, et al. Single-centre experience with
  the frozen elephant trunk technique in 251 patients over
  15\selectlanguage{english} years\selectlanguage{english}+.\emph{Eur J Cardio-Thoracic Surg} . 2017;52(5):858\selectlanguage{english}-866.
\item
  Lombardi J V., Cambria RP, Nienaber CA, et al. Prospective multicenter
  clinical trial (STABLE) on the endovascular treatment of complicated
  type B aortic dissection using a composite device design. \emph{J Vasc
  Surg} . 2012;55(3):629-640.e2.
\item
  Bavaria JE, Brinkman WT, Hughes GC, et al. Outcomes of Thoracic
  Endovascular Aortic Repair in~Acute Type B Aortic Dissection: Results
  From the~Valiant United States Investigational Device Exemption
  Study.\emph{Ann Thorac Surg} . 2015;100(3):802\selectlanguage{english}-809.
\item
  Guan Y, Lin J, Dong Z, Wang L. Comparative Study of the Effect of
  Structural Parameters on the Flexibility of Endovascular Stent
  Grafts.\emph{Adv Mater Sci Eng} . 2018;2018:1\selectlanguage{english}-10.
\item
  Matsumoto T, Matsubara Y, Aoyagi Y, et al. Radial force measurement of
  endovascular stents: Influence of stent design and
  diameter.\emph{Vascular} . 2016;24(2):171\selectlanguage{english}-176.
\item
  Bodell BD, Taylor AC, Patel PJ. Thoracic Endovascular Aortic Repair:
  Review of Current Devices and Treatments Options. \emph{Tech Vasc
  Interv Radiol} . 2018;21(3):137\selectlanguage{english}-145.
\item
  Matsumoto T, Inoue K, Tanaka S, et al. Radial forces of stents used in
  thoracic endovascular aortic repair and bare self-expanding nitinol
  stents measured ex vivo -- Rapid rescue for obstruction of the
  innominate artery using bare self-expanding nitinol
  stents.\emph{Vascular} . 2017;25(1):36\selectlanguage{english}-41.
\item
  Zhou X, Yang F, Gong X, Zhao M, Zheng Y, Sun Z. Development of new
  endovascular stent-graft system for type B thoracic aortic dissection
  with finite element analysis and experimental verification. \emph{J
  Mater Sci Technol} . 2019;35(11):2682\selectlanguage{english}-2692.
\item
  Montagner M, Kofler M, Heck R, et al. Initial experience with the new
  type A arch dissection stent: restoration of supra-aortic vessel
  perfusion. \emph{Interact Cardiovasc Thorac Surg} .
  2021;33(2):276\selectlanguage{english}-283.
\item
  Montagner M, Kofler M, Seeber F, et al. The arch remodelling stent for
  DeBakey I acute aortic dissection: experience with 100
  implantations.\emph{Eur J Cardio-Thoracic Surg} . 2022;62(2).
\end{enumerate}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Baseline Characteristics} & \textbf{Value}\tabularnewline
\midrule
\endhead
Age (y) & 61 (51-69)\tabularnewline
Male Gender (\%) & 75 (3/4)\tabularnewline
Malperfusion (\%) & 50 (2/4)\tabularnewline
Preoperative Stroke (\%) & 25 (1/4)\tabularnewline
Hypertension (\%) & 100 (4/4)\tabularnewline
COPD (\%) & 0\tabularnewline
Reoperation & 0\tabularnewline
\bottomrule
\end{longtable}

Table 1: Baseline Characteristics of the study population.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Characteristic} & \textbf{Value}\tabularnewline
\midrule
\endhead
Successful device deployment & 100\%\tabularnewline
David V procedure & 100\%\tabularnewline
Mean cardiopulmonary bypass time (min) & 113(+/-8)\tabularnewline
Mean cross clamping time (min) & 85(+/-6)\tabularnewline
Mean cerebral perfusion time (min) & 15(+/-2)\tabularnewline
\bottomrule
\end{longtable}

Table 2: Procedural data.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Mortality and serious adverse events} &
\textbf{Value}\tabularnewline
\midrule
\endhead
30-day mortality & 0\%\tabularnewline
Neurological deficit & 25\% (1 patient)\tabularnewline
Acute renal failure requiring hemodialysis & 50\% (2
patients)\tabularnewline
Hemorrhagic shock & 25\% (1 patient)\tabularnewline
Aortic injury associated with device implantation & 0\%\tabularnewline
Device related reintervention & 0\%\tabularnewline
Stent compression & 25\% (1 patient)\tabularnewline
\bottomrule
\end{longtable}

Table 3: Mortality and Serious Adverse Events.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1: Expanded Ascyrus Medical Dissection Stent.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2: Computed tomography angioscanner showing the deployed AMDS in
the true lumen.

\textbf{Hosted file}

\verb`image3.emf`  available at \url{https://authorea.com/users/402067/articles/589094-ascyrus-medical-dissection-stent-in-the-treatment-of-acute-type-a-aortic-dissection-a-first-hand-experience}

Figure 3: Comparison of the CT measurements of the different aortic
diameters.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

Figure 4: Compression of the AMDS at the isthmus in one patient.

\selectlanguage{english}
\FloatBarrier
\end{document}

