Type B aortic dissection after PEARS implantation: a series of two cases

Type B aortic dissection after PEARS implantation: a series of two cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Type B aortic dissection after PEARS implantation: a series of two cases Alejandro González-Caldevilla Fernandez, Shivan Edmond Saith, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6706222/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Perspective statement: The cases presented highlight a potential risk of distal aortic complications specially type B aortic dissection in syndromic patients previously considered low-risk and where not previously reported before. These findings underscore the need for vigilant long-term surveillance and may influence surgical planning and patient selection in heritable aortic conditions. Aorta PEARS type B dissection frozen elephant trunk Figures Figure 1 Figure 2 Introduction There is no current report in literature regarding Type B aortic dissection (TBAD) following personalized external aortic root support (PEARS) implantation [1, 2]. We present two recent cases of patients with genetic aortic connective tissue syndromes who required extensive surgical management after having developed complicated TBADs post PEARS surgery. Both patients survived and are under continuous surveillance. PATIENT #1 A 32-year-old woman with Loeys-Dietz [ 1 ] syndrome underwent ExoVasc® PEARS implantation on 10/02/2022. After two unremarkable years, she was admitted at Royal Victoria Infirmary, Newcastle for elective caesarean section at term on the 11/03/2024. Three days after delivering, she reported abdominal and lower back pain. She was discharged three days postpartum without complication but had abdominal and lower back pain on the 3/11/2024. CTA performed next day identified acute TBAD with an entry tear distal to the left subclavian artery, true lumen narrowing with compromised mesenteric flow down to the iliac arteries (Fig. 1 left). A 15 cm ischemic small bowel segment with pneumatosis intestinalis and mesenteric venous gas was also identified on CTA. Distal endovascular repair was not suitable for the patient and therefore, open surgery was performed. Due to increasing lactate levels and the need for escalating doses of vasopressors, she was transferred to St Bartholomew's Hospital on 16/03/2024. According to the intraoperative findings, the patient had a non-A non-B dissection of the aortic arch. She underwent redo-sternotomy and total aortic arch replacement (distal ascending to zone 2) with a 26x28x150 mm Thoraflex™ Hybrid prosthesis. Patient was taken off bypass under high inotropic support. After the surgery finished, immediate laparotomy showed necrotic tissue of the ascending and proximal transverse colon, vast small bowel extension in addition to liver hypoperfusion and ischemic gallbladder. The patient underwent right hemicolectomy, extensive small bowel resection, and cholecystectomy. Two days later, her chest and abdomen which were temporarily packed were closed. After extubation and follow-up CTA on 21/03/2024 which revealed good results, she was transferred to Freeman Hospital ICU and was later discharged home on parenteral nutrition. She is awaiting bowel transplantation for the time being. PATIENT #2 A 40-year-old male with Marfan syndrome [ 2 ] had a 95% ExoVasc® PEARS previously implanted four years ago. He presented with acute chest pain on 27/06/2023. On CTA, TBAD was seen, with a 50 mm proximal descending thoracic aorta (DTA) dilatation that extended to both iliac arteries. The patient complained about pain despite optimal medical management, and repeated imaging indicated rapid DTA expansion to 53 mm. On 11/07/2023, he underwent an emergency DTA replacement with a 26 mm Gelweave™ graft via left thoracotomy under left heart bypass. Since the patient had severe bleeding and hypoxemia, abdominal intervention was delayed. During the postoperative course, he developed pneumonia with left lung collapse, needing reintubation for type 2 respiratory failure. During bronchoscopy, the blood-mucus was removed from the left main bronchus. Later, CTA showed that the PEARS-covered distal ascending aorta was retrograde dissected, probably due to arch clamping during DTA repair. On 23/07/2024, he underwent redo-sternotomy and FET procedure with a 26x28x100 mm ThoraflexTM Hybrid prosthesis to replace the ascending aorta and aortic arch. His recovery was unremarkable, and he was discharged on 03/08/2024. The following imaging showed the abdominal visceral aorta dilated up to 59 mm and needed to be managed surgically, which he is awaiting. DISCUSSION ExoVasc® PEARS is used to prevent the dilation, aneurysm, or dissection of the ascending aorta in patients with heritable connective tissues disorders. Despite over 1200 procedures worldwide, data on long-term outcomes remains limited due to the absence of centralized registries. These two cases represent the first documented instances of complicated TBAD post-PEARS implantation. Both patients required extensive surgical intervention and are under ongoing monitoring. Although PEARS offers the potential to avoid mechanical aortic valve replacement and preserve the native root and ascending aorta, its rigid structure may contribute to downstream aortic instability, potentially increasing the risk of TBAD, as Singh et al previously hypostatised [ 2 , 3 , 4 ]. Retrograde dissection into the PEARS -encased aorta, as observed in patient #2, raises concerns regarding intraoperative handling and long-term tissue dynamics [ 5 ]. Histological and physiological studies are needed to assess the downstream impact of PEARS and better inform surgical strategies. Continuous surveillance of PEARS [ 1 ] recipients is essential to identify and report complications, optimize patient selection, and refine procedural techniques. Further research is needed to balance the benefits of root protection with the risks of distal pathology in patients with syndromic thoracic aortic disease. During the preparation of this work the author used Chat GPT to summarize the medical history of each case report. After using this tool, the author reviewed and edited the content as needed and take full responsibility for the content of the publication. Abbreviations TBAD: type B aortic dissection PEARS: personalized external aortic root support CTA: computerized tomography angiogram ICU: intensive care unit DTA: descending thoracic aorta Declarations Disclosure statement: The author declares that he has no relevant or material financial interests that relate to the research described in this paper. Funding statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Informed Consent Statement: both patients agreed on consenting their clinical information and imaging to be shared for scientific purposes prior to the operation in our institution by signing the corresponding consent form. References Pepper J, Golesworthy T, Austin C, et al. Personalized external aortic root support (PEARS): a narrative review. J Thorac Cardiovasc Surg. 2024;168(6):1628-1631. doi:10.1016/j.jtcvs.2024.07.016 Van Hoof L, Lamberigts M, Noé D, et al. Matched comparison between external aortic root support and valve-sparing root replacement. Heart. 2023;109(10):832-838. doi:10.1136/heartjnl-2022-321840 Zhou X, Wang X, Li J, et al. Fate of the distal aorta following root replacement in Marfan syndrome. Front Cardiovasc Med. 2023;10:1186181. doi:10.3389/fcvm.2023.1186181 Zakko J, Ghincea C, Reece TB. Future paradigms of aortic dissection. Cardiol Clin. 2024. doi:10.1016/j.ccl.2024.12.001 Hameed I, Cifu AS, Vallabhajosyula P. Management of thoracic aortic dissection. JAMA. 2023;329(9):756. doi:10.1001/jama.2023.0265 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Sep, 2025 Reviews received at journal 26 Jul, 2025 Reviews received at journal 25 Jul, 2025 Reviews received at journal 24 Jul, 2025 Reviews received at journal 23 Jul, 2025 Reviewers agreed at journal 20 Jul, 2025 Reviewers agreed at journal 19 Jul, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers invited by journal 15 Jul, 2025 Editor assigned by journal 21 May, 2025 Submission checks completed at journal 21 May, 2025 First submitted to journal 20 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6706222","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":486383737,"identity":"773a2606-1ec2-4981-9834-a5031081c241","order_by":0,"name":"Alejandro González-Caldevilla Fernandez","email":"data:image/png;base64,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","orcid":"","institution":"St Bartholomew's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Alejandro","middleName":"González-Caldevilla","lastName":"Fernandez","suffix":""},{"id":486383738,"identity":"57e671be-e084-47ee-b20a-e314a68fd1ff","order_by":1,"name":"Shivan Edmond Saith","email":"","orcid":"","institution":"Queen Mary University of London","correspondingAuthor":false,"prefix":"","firstName":"Shivan","middleName":"Edmond","lastName":"Saith","suffix":""},{"id":486383739,"identity":"3d3b17bb-b374-4f86-812c-0c718817f13f","order_by":2,"name":"Farhin Holia","email":"","orcid":"","institution":"St Bartholomew's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Farhin","middleName":"","lastName":"Holia","suffix":""},{"id":486383740,"identity":"60fc5fe0-66f0-49c6-9a70-0b8b44b17838","order_by":3,"name":"Ana Lopez-Marco","email":"","orcid":"","institution":"St Bartholomew's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Lopez-Marco","suffix":""},{"id":486383741,"identity":"f2ba2b68-aaf7-4c6c-9b5f-50777c771a1f","order_by":4,"name":"Aung Ye Oo","email":"","orcid":"","institution":"St Bartholomew's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Aung","middleName":"Ye","lastName":"Oo","suffix":""}],"badges":[],"createdAt":"2025-05-20 09:38:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6706222/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6706222/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87318768,"identity":"0be7e529-e048-4a3d-a099-b3d6cf397ffd","added_by":"auto","created_at":"2025-07-22 16:18:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":471266,"visible":true,"origin":"","legend":"\u003cp\u003ePatient 1 sequence of CTA imaging is shown here. \u003cstrong\u003eA. \u003c/strong\u003eCTA performed after onset of pain, showing TBAD distal to the subclavian, with extreme narrowing of the true aortic lumen (\u003cem\u003eyellow arrows\u003c/em\u003e). 3D reconstructions where PEARS can be differentiated from native aorta (\u003cem\u003eyellow circles\u003c/em\u003e). \u003cstrong\u003eB\u003c/strong\u003e. Post FET CTA showing the remodelling of the native aorta distal to the Thoraflex stent (\u003cem\u003ered arrow\u003c/em\u003e). CTA (computerized tomography angiogram), TBAD (type B aortic dissection), PEARS (personalized external aortic root support), FET (frozen elephant trunk)\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6706222/v1/51c94df9cb0158adc9caa9bd.png"},{"id":87318772,"identity":"ec3c779a-9469-4283-9298-822952309f5d","added_by":"auto","created_at":"2025-07-22 16:18:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":645332,"visible":true,"origin":"","legend":"\u003cp\u003ePatient 2 sequence of CTA imaging is shown here. \u003cstrong\u003eA.: \u003c/strong\u003eFirst CTA after admitting the patient with symptoms shows TBAD distal to the subclavian (\u003cem\u003ered arrow\u003c/em\u003e) with 3D reconstruction where previous PEARS is visible. \u003cstrong\u003eB.: \u003c/strong\u003eCTA after DTA replacement, 3D reconstruction shows the DTA dacron graft. Retrograde type A dissection is clearly seen (\u003cem\u003eblue circles\u003c/em\u003e) and flap could be seen in 3D reconstruction (\u003cem\u003eblue arrow\u003c/em\u003e). \u003cstrong\u003eC.: \u003c/strong\u003eResult after FET replacement, PEARS to Thoraflex proximal anastomosis (\u003cem\u003eyellow arrow\u003c/em\u003e). CTA (computerized tomography angiogram), TBAD (type B aortic dissection), PEARS (personalized external aortic root support), DTA (descending thoracic aorta), FET (frozen elephant trunk).\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-6706222/v1/ee0592f41c0bb52a1ea478f3.png"},{"id":87320886,"identity":"c9d9d86f-084d-48da-aa6a-975ec577d1a5","added_by":"auto","created_at":"2025-07-22 16:34:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1359213,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6706222/v1/e8fd8ce9-8e2d-429b-a785-16eb3578424f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Type B aortic dissection after PEARS implantation: a series of two cases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere is no current report in literature regarding Type B aortic dissection (TBAD) following personalized external aortic root support (PEARS) implantation [1, 2]. We present two recent cases of patients with genetic aortic connective tissue syndromes who required extensive surgical management after having developed complicated TBADs post PEARS surgery. Both patients survived and are under continuous surveillance.\u003c/p\u003e"},{"header":"PATIENT #1","content":"\u003cp\u003eA 32-year-old woman with Loeys-Dietz [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] syndrome underwent ExoVasc® PEARS implantation on 10/02/2022. After two unremarkable years, she was admitted at Royal Victoria Infirmary, Newcastle for elective caesarean section at term on the 11/03/2024. Three days after delivering, she reported abdominal and lower back pain. She was discharged three days postpartum without complication but had abdominal and lower back pain on the 3/11/2024. CTA performed next day identified acute TBAD with an entry tear distal to the left subclavian artery, true lumen narrowing with compromised mesenteric flow down to the iliac arteries (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e left). A 15 cm ischemic small bowel segment with pneumatosis intestinalis and mesenteric venous gas was also identified on CTA. Distal endovascular repair was not suitable for the patient and therefore, open surgery was performed.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDue to increasing lactate levels and the need for escalating doses of vasopressors, she was transferred to St Bartholomew's Hospital on 16/03/2024. According to the intraoperative findings, the patient had a non-A non-B dissection of the aortic arch. She underwent redo-sternotomy and total aortic arch replacement (distal ascending to zone 2) with a 26x28x150 mm Thoraflex™ Hybrid prosthesis. Patient was taken off bypass under high inotropic support. After the surgery finished, immediate laparotomy showed necrotic tissue of the ascending and proximal transverse colon, vast small bowel extension in addition to liver hypoperfusion and ischemic gallbladder. The patient underwent right hemicolectomy, extensive small bowel resection, and cholecystectomy.\u003c/p\u003e\u003cp\u003eTwo days later, her chest and abdomen which were temporarily packed were closed. After extubation and follow-up CTA on 21/03/2024 which revealed good results, she was transferred to Freeman Hospital ICU and was later discharged home on parenteral nutrition. She is awaiting bowel transplantation for the time being.\u003c/p\u003e"},{"header":"PATIENT #2","content":"\u003cp\u003eA 40-year-old male with Marfan syndrome [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] had a 95% ExoVasc® PEARS previously implanted four years ago. He presented with acute chest pain on 27/06/2023. On CTA, TBAD was seen, with a 50 mm proximal descending thoracic aorta (DTA) dilatation that extended to both iliac arteries. The patient complained about pain despite optimal medical management, and repeated imaging indicated rapid DTA expansion to 53 mm.\u003c/p\u003e\u003cp\u003eOn 11/07/2023, he underwent an emergency DTA replacement with a 26 mm Gelweave™ graft via left thoracotomy under left heart bypass. Since the patient had severe bleeding and hypoxemia, abdominal intervention was delayed. During the postoperative course, he developed pneumonia with left lung collapse, needing reintubation for type 2 respiratory failure. During bronchoscopy, the blood-mucus was removed from the left main bronchus. Later, CTA showed that the PEARS-covered distal ascending aorta was retrograde dissected, probably due to arch clamping during DTA repair.\u003c/p\u003e\u003cp\u003eOn 23/07/2024, he underwent redo-sternotomy and FET procedure with a 26x28x100 mm ThoraflexTM Hybrid prosthesis to replace the ascending aorta and aortic arch. His recovery was unremarkable, and he was discharged on 03/08/2024. The following imaging showed the abdominal visceral aorta dilated up to 59 mm and needed to be managed surgically, which he is awaiting.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eExoVasc\u0026reg; PEARS is used to prevent the dilation, aneurysm, or dissection of the ascending aorta in patients with heritable connective tissues disorders. Despite over 1200 procedures worldwide, data on long-term outcomes remains limited due to the absence of centralized registries. These two cases represent the first documented instances of complicated TBAD post-PEARS implantation. Both patients required extensive surgical intervention and are under ongoing monitoring.\u003c/p\u003e\u003cp\u003eAlthough PEARS offers the potential to avoid mechanical aortic valve replacement and preserve the native root and ascending aorta, its rigid structure may contribute to downstream aortic instability, potentially increasing the risk of TBAD, as Singh et al previously hypostatised [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRetrograde dissection into the PEARS -encased aorta, as observed in patient #2, raises concerns regarding intraoperative handling and long-term tissue dynamics [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Histological and physiological studies are needed to assess the downstream impact of PEARS and better inform surgical strategies.\u003c/p\u003e\u003cp\u003eContinuous surveillance of PEARS [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] recipients is essential to identify and report complications, optimize patient selection, and refine procedural techniques. Further research is needed to balance the benefits of root protection with the risks of distal pathology in patients with syndromic thoracic aortic disease.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDuring the preparation of this work the author used Chat GPT to summarize the medical history of each case report. After using this tool, the author reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/em\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eTBAD: type B aortic dissection\u003c/li\u003e\n \u003cli\u003ePEARS: personalized external aortic root support\u003c/li\u003e\n \u003cli\u003eCTA: computerized tomography angiogram\u003c/li\u003e\n \u003cli\u003eICU: intensive care unit\u003c/li\u003e\n \u003cli\u003eDTA: descending thoracic aorta\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003eDisclosure statement: The author declares that he has no relevant or material financial interests that relate to the research described in this paper.\u003c/p\u003e\n\u003cp\u003eFunding statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eInformed Consent Statement: both patients agreed on consenting their clinical information and imaging to be shared for scientific purposes prior to the operation in our institution by signing the corresponding consent form.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePepper J, Golesworthy T, Austin C, et al. Personalized external aortic root support (PEARS): a narrative review. J Thorac Cardiovasc Surg. 2024;168(6):1628-1631. doi:10.1016/j.jtcvs.2024.07.016\u003c/li\u003e\n\u003cli\u003eVan Hoof L, Lamberigts M, No\u0026eacute; D, et al. Matched comparison between external aortic root support and valve-sparing root replacement. Heart. 2023;109(10):832-838. doi:10.1136/heartjnl-2022-321840\u003c/li\u003e\n\u003cli\u003eZhou X, Wang X, Li J, et al. Fate of the distal aorta following root replacement in Marfan syndrome. Front Cardiovasc Med. 2023;10:1186181. doi:10.3389/fcvm.2023.1186181\u003c/li\u003e\n\u003cli\u003eZakko J, Ghincea C, Reece TB. Future paradigms of aortic dissection. Cardiol Clin. 2024. doi:10.1016/j.ccl.2024.12.001\u003c/li\u003e\n\u003cli\u003eHameed I, Cifu AS, Vallabhajosyula P. Management of thoracic aortic dissection. JAMA. 2023;329(9):756. doi:10.1001/jama.2023.0265\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aorta, PEARS, type B dissection, frozen elephant trunk","lastPublishedDoi":"10.21203/rs.3.rs-6706222/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6706222/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePerspective statement: The cases presented highlight a potential risk of distal aortic complications specially type B aortic dissection in syndromic patients previously considered low-risk and where not previously reported before. 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