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\begin{document}

\title{Preoperative Evaluation of Aortic Calcification by Computed Tomography
in Thoracic Aortic Disease}



\author[1]{Ryo Suzuki}%
\author[1]{Akihito Mikamo}%
\author[1]{Sari Tsubone}%
\author[1]{Kazumasa Matsunaga}%
\author[1]{Yuutaro Matsuno}%
\author[1]{Hiroshi Kurazumi}%
\author[1]{Kimikazu Hamano}%
\affil[1]{Yamaguchi University School of Medicine}%


\vspace{-1em}



  
  \date{May 17, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Background: Computed tomography (CT) is a useful tool for the
identification of calcified lesions in the aorta. However, no
quantitative evaluation has been established to assess the applicability
of simple anastomosis preoperatively. We conducted this retrospective
study to establish a reference range of the maximal CT value for
application of simple anastomosis. Methods: 122 consecutive patients
underwent replacement of the thoracic aorta between 2007-2011, excluding
those with acute aortic dissection. The patients were divided into two
groups: those who could undergo simple anastomosis (Simple group:n=105),
and those who required endarterectomy prior to anastomosis (Manipulation
group:n=17). The maximal CT value at the anastomosis site was calculated
by an imaging software. Results: The mean maximal CT value (Hounsfield
unit: HU) was significantly higher in the Manipulation group (638.1 \selectlanguage{ngerman}±
269.5 {[}166-1304{]}) than in the Simple group (94.7 ± 171.5
{[}0-790{]}) (p\textless{}0.0001). The maximal CT value enabled us to
predict the simple anastomosis with the area under the receiver
operating characteristic curve of 0.96 (p\textless{}0.0001). The cut-off
value was 325 HU (sensitivity 94.1\%, specificity 81.7\%). The 10-year
survival rate was significant lower in the Manupilation group (11.8\%)
than in the Simple group (43.2\%). In the multivariate analysis, age
(Hazard Ratio {[}HR{]}:1.073), Hypertension (HR:2.382) and maximal CT
value (HR:1.001) were independently associated with long-term mortality.
Conclusions: Preoperative evaluation of the maximal CT value is a useful
tool in predicting whether simple anastomosis is applicable or not, in
the thoracic aortic surgery. Maximal CT value is a risk factor for
long-term mortality.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Introduction:} An aging society brings with it a wide range of
medical problems, one of which is an increasing number of patients with
a severely calcified aorta\textsuperscript{1}. These patients, who often
require thoracic aortic surgery, may encounter numerous obstacles during
the surgery. For one, the calcified intima interferes with suturing of
the aorta, thereby renders aortic anastomosis to be difficult. Moreover,
should the calcified aorta be forcibly sutured, the aortic wall may
split and lead to bleeding or rupture. In view of the increased risk of
complications that would affect the surgical plan and outcome, it is
important to predict the extent of aortic calcification preoperatively.
Computed tomography (CT) is a useful device for diagnosis of calcified
lesions, but no quantitative evaluation has been established to predict
whether simple anastomosis or any additional manipulation such as
endarterectomy is required during operation. Here, we conducted this
retrospective study to establish the reference value range of the
maximal CT value for application of simple anastomosis in thoracic
aortic surgery.

\textbf{Patients and Methods:} Between 2007 and 2011, 122 consecutive
patients (mean age = 67 \selectlanguage{ngerman}± 14 years) underwent replacement of the
thoracic aorta were included in this study. Patients with acute aortic
dissection were excluded, though those with chronic aortic dissection
were included such as dissecting aortic aneurysm. We divided the 122
patients into 2 groups, 105 patients (mean age = 66 ± 14) underwent
simple anastomosis (Simple group), and 17 patients (mean age = 73 ± 6)
required endarterectomy before undergoing anastomosis (Manipulation
group). Preoperative CT scans were taken and the maximal CT value at the
anastomosis site in comparison with postoperative CT was calculated
using a diagnostic imaging software (AZE Virtual Place Raijin, Aze Ltd.,
Tokyo, Japan), based on the peak Hounsfield unit (HU) of the detected
calcified lesions. When it was less than 130 HU, we defined 0 HU at the
area. The institutional review board approved this retrospective study.
Informed consent was obtained from all patients.

\textbf{Surgical technique:}

In the cases of ascending aorta, aortic arch, and aortic root
replacement, the chest was opened via a median sternotomy under general
anesthesia. The bilateral axillary arteries were exposed for arterial
cannulation. Cardiopulmonary bypass (CPB) was established with bilateral
axillary arterial cannulation and bicaval drainage. The patient's body
temperature was cooled down to 25°C and measured rectally, followed by
implementation of lower body circulatory arrest with moderate
hypothermia. Antegrade selective cerebral perfusion was established by
axillary perfusion with clamped brachiocephalic and left subclavian
arteries and by direct cannulation of the left common carotid artery.
Antegrade cold blood cardioplegia was administered to achieve and
maintain cardiac arrest. Open distal anastomosis was first performed.
The arch vessels were reconstructed individually, and finally, proximal
anastomosis was completed.

In the cases of descending aorta and thoracoabodominal aorta
replacement, the chest was opened via a intercostal space under general
anesthesia.The femoral artery and vein were exposed for cannulation. CPB
was established with the arterial cannulation and right ventricular
drainage via femoral vein. If possible, anastomosis was performed by
aortic clamping with normal temperature. If not possible, the patients'
body temperature was cooled down to 25°C, mesured rectally, followed by
the implementation of lower body circulatory arrest with moderate
hypothermia. Open proximal and distal anastomosis were performed.

\textbf{Patient follow-up}

Complete follow-up data were available for hospital survivors. The mean
follow-up period was 83 ± 44 months (median, 98 months). The follow-up
rate was 100\%.

\textbf{Statistical analyses:} Quantitative data are expressed as mean ±
standard deviation (SD). Statistical comparisons between the two groups
were performed using an unpaired Student's t test or the Fisher's exact
test and a log-rank test using the JMP 14 (SAS Institute Inc., Cary, NC,
USA). P values of \textless{}0.05 were considered statistically
significant. Significance was determined when p\textless{}0.05. The
reference value range of the maximal CT value for simple anastomosis
application was determined by the area under the receiver operating
characteristic (ROC) curve. Results of quantitative studies are
presented as mean ± SD. Survival was analyzed by the Kaplan-Meier
method. Multivariable Cox proportional hazard analysis was performed to
exclude the confounding factors and identify independent risk factors
for long-term survival.

\textbf{Results:} The preoperative characteristics of the two groups are
presented in \textbf{Table 1} . The number of female, smoker and
arteriosclerosis were significantly higher in the Manipulation group
(p\textless{}0.05). The Hemoglobin and eGFR were significantly higher,
and the body weight was significantly heavier in the Simple group
(p\textless{}0.05). One patient in the Simple group was a dialysis
patient. \textbf{Table 2} shows the replacement range of the aorta in
each group. Aortic arch replacement was most common in the Simple group
(50.5\%), while ascending and descending aorta replacement accounted for
the majority in the Manipulation group (52.9\% and 17.6\%,
respectively). The JapanSCORE has been devised as the Japanese original
risk model for cardiovascular surgery\textsuperscript{2}. JapanSCORE was
similar between the two groups. The replacement range of the aorta was
wider in the Simple group rather than in the Manipulation group
(p\textless{}0.01). The concomintant procedure was not significantly
different between the two groups. Perioperative data are summarized
in\textbf{Table 3} . Operation time and cardiopulmonary bypass time were
shorter in the Manipulation group. Hospital death rate was 1.9\% (2/105)
in the Simple group and 5.9\% (1/17) in the Manipulation group.
Postoperative bleeding and cerebral infarction were occurred in each
group. These complications were not related to the anastomosis site.
There were no significant difference in postoperative stay, intensive
care unit stay, and the amount of bleeding.

The distribution of maximal CT value is shown in \textbf{Figure 1} . The
mean maximal CT value (Hounsfield unit: HU) was 94.7 ± 171.5 (0-790) in
the Simple group, and 638.1 ± 269.5(166-1304) in the Manipulation group.
The maximal CT value was significantly higher in the Manipulation group
than that in the Simple group. The ROC curve revealed that the best
cut-off value for the prediction of manipulation was 325 HU (sensitivity
94.1\%, specificity 81.7\%) (\textbf{Figure 2} ). The area under the
curve was calculated to be 0.96 (p\textless{}0.0001).

The postoperative 10-year actual survival rates of the patients are
shown in \textbf{Figure 3} . The 5-year and 10-year survival rate were
69.7\% and 38.3\% in all patients (\textbf{Figure 3A} ). The 5-year and
10-year survival rate were 73.3\% and 43.2\% in the Simple group and
47.6\% and 11.2\% in the Manipulation group (\textbf{Figure 3B} ). The
postoperative survival rate in the Manipulation group was significantly
lower than those in the Simple group (p = 0.001). The variables that had
p values \textless{} 0.10 according to the univariate Cox analyses of
age, hypertension, preoperative eGFR, required amount of blood
transfusion, preoperative hemoglobin, Japan SCORE, Manipulation, body
wight, and maximal CT value. Multivariate Cox proportional hazard
analysis determined that age (Hazard Ratio {[}HR{]}: 1.073),
hypertension (HR: 2.38) and maximal CT (HR: 1.001) were independently
associated with long-term mortality.

\textbf{Comment:} Severe calcified lesion of the aorta increases the
risk of complications after cardiovascular surgery\textsuperscript{3}.
Generally, if calcification interferes with anastomosis, it requires
root replacement\textsuperscript{4} or a larger extent of aortic
replacement beyond the planned anastomosis site, which also increases
the operative risk. If possible, the extended range of aortic
replacement should be reduced by manipulation of the calcified lesion of
the aorta. Recently, several papers have reported novel manipulation
methods of a calcified aorta, such as
endarterectomy\textsuperscript{5}and covering with bovine
pericardium\textsuperscript{6}. If preoperative assessment are able to
identify to be needed manipulation of the aorta, well-planned strategies
can be established before surgery.

CT is an ideal tool for diagnosis of calcified lesions. It is minimally
invasive and can be performed on almost all patients without a history
of claustrophobia. In Japan, CT scans are a common preoperative
examination for cardiovascular surgery. CT can detect various vascular
abnormalities including calcification and anomalies of aorta. Indeed,
Lee and colleagues\textsuperscript{7} suggested that preoperative CT may
help in identifying and avoiding aortic areas known to form emboli and
cause a stroke after cardiac operation\textsuperscript{8}. In this
study, we evaluated whether the maximal CT value could predict the
application of simple anastomosis or reqirement of aortic manipulation
in patients with thoracic aortic disease. CT values range from -1000 to
1000 HU, depending on the density; air is -1000 HU, water is 0 HU and
bone is 1000 HU. The higher the CT value is the more calcified the
aorta. We found that a calcified aorta with a maximal CT value of 325 HU
or more requires manipulation prior to anastomosis. Therefore, if the
maximal CT value of the planned anastomosis site is 325 HU or more, a
manipulation method or another anastomosis site should be planned before
the operation.

In this study, endarterectomy was used for the manipulation of all
severely calcified aortas. We were concerned that endarterectomy may
increase the risk of aortic dissection, but no such incident was
observed. Svensson and colleagues\textsuperscript{5} reported that the
intima and media are densely adherent to the adventitia in patients with
a calcified aortic wall. If the media was prone to peel at a site distal
to the anastomosis, we hypothesized that aortic dissection was prevented
by fixing sutures using 5-0 monofilament. The anastomosis site was
reinforced by a continuous suture by the 4-0 monofilament suture and a
circumferential horizontal matteress suture with 4-0 monofilament
sutures with double pledgets. The clinical results were evaluated again
one year after the surgery and CT showed no dissection or pseudoaneurysm
in any of the patients. Furthermore, the total number of 30-day
operative deaths and cerebral infarction amounted to three and one
respectively. We concluded that the operative results were satisfactory,
even for patients with a severely calcified aorta.

We showed strong evidence that age, hypertension, and maximal CT value
are independently associated with long-term mortality. The follow up
rate is 100\%, and this result is from 10 years actual survival. In
generally, age and hypertension are related to long-term mortality, so
the results of this study provide the first evidence that maximal CT
value may be a useful tool for the increase in late mortality.
Furthermore, though Agatston and colleagues\textsuperscript{9} reported
that CT protocol and coronary calcification score were determined by 20
slices from 3-mm slice CT images. And AZE Virtual Place Raijin, a
workstation of medical imaging, played an important role in this study.
Calcium scoring is one of the analysis options of the software. This
software automatically calculates voxel, volume, minimal CT value,
maximal CT value, average CT value, standard deviation, and Agatston
score from selection of CT images. We used ``maximal CT value'' in this
study as it was necessary to evaluate the calcification at the
anastomosis site. The software was originally set to calculate calcium
scoring (Agatston score) of coronary arteries from 3-mm slice CT images,
but we changed the setting to 5-mm slices, because this is the normal
width under CT imaging. The maximal CT value may not be included at
anastomosis site. However, it should be noted that the maximal CT value
does not change depending on the slice width and scanner. Furtehrmore,
we need only 2 slices CT image at proximal and distal anastomosis site.
And either 3 mm or 10 mm CT image is acceptable. In the future, we hope
that the maximal CT value becomes one of the standard preoperative
assessments to decide the operation plan for thoracic aortic surgery. In
conclusion, preoperative evaluation of the maximal CT value can help us
to predict whether simple anastomosis is applicable to patients with
thoracic aortic disease.

\textbf{Conclusions} : Preoperative evaluation of the maximal CT value
is a useful tool in predicting whether simple anastomosis is applicable
or not, in the thoracic aortic surgery. If the maximal CT value is 325
HU or more, a manipulation method or another anastomosis site should be
planned before the operation. Furthermore, maximal CT value is
individual's risk associated with late mortality. Further study is
needed to clarify the mechanisms that long-term mortality increases by
the CT value.

\textbf{Author contributions} :

\textbf{Ryo Suzuki} : Concept/design, Data analysis/interpretation,
Drafting article, Statistics, Data collection

\textbf{Akihito Mikamo} : Concept/design, Data analysis/interpretation,
Critical revision of article

\textbf{Tsubone Sari, Kazumasa Matsunaga, Matsuno Yuutaro, Hiroshi
Kurazumi} : Data collection

\textbf{Kimikazu Hamano} : Critical revision of article, Approval of
article

\textbf{References}

1. Johnson RC, Leopold JA, Loscalzo J. Vascular calcification:
pathobiological mechanisms and clinical implications. Circ Res.
2006;99:1044-1059.

2. Noboru Motomura, Hiroaki Miyata, Hiroyuki Tsukihara, Shinichi
Takamoto, from the Japan Cardiovascular Surgery Database Organization.
Risk model of thoracic aortic surgery in 4707 cases from a nationwide
single-race population through a web-based data entry system: The first
report of 30-day and 30-day operative outcome risk models for thoracic
aortic surgery. Circulation 2008; 118: S153-159.

3. van der Linden J, Hadjinikolaou L, Bergman P, Lindblom D.
Postoperative stroke in cardiac surgery is related to the location and
extent of atherosclerotic disease in the ascending aorta. J Am Coll
Cardiol. 2001;38:131-135.

4. Tsuneyoshi H, Doi K, Yamanaka K. Bentall procedure in a patient with
severely calcified ''porcelain'' aorta. J Card Surg. 2009;24:716-718.

5. Svensson LG, Sun J, Cruz HA, Shahian DM. Endarterectomy for calcified
porcelain aorta associated with aortic valve stenosis. Ann Thorac Surg.
1996;61:149-152.

6. Shimizu H, Miyaki Y, Kaneko T, Suzuki R, Kudo M, Yozu R. Total arch
replacement with endarterectomy of the ascending aorta in a patient with
aortic arch aneurysm and porcelain aorta. Ann Thorac Cardiovasc Surg.
2008;14:402-404.

7. Lee R, Matsutani N, Polimenakos AC, Levers LC, Lee M, Johnson RG.
Preoperative noncontrast chest computed tomography identifies potential
aortic emboli. Ann Thorac Surg. 2007;84:38-41.

8. Butler CG, Ho Luxford JM, Huang CC, et al. Aortic Atheroma Increases
the Risk of Long-Term Mortality in 20,000 Patients. Ann Thorac Surg.
2017;104:1325-1331

9. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr,
Detrano R. Quantification of coronary artery calcium using ultrafast
computed tomography. J Am Coll Cardiol. 1990;15:827-832.

\textbf{Figure legends}

\textbf{Figure 1} . The distribution of the maximal CT value In the
Simple group {[}A{]}, the minimum CT value was 0, the maximum was 790,
and the average was 94.7 ± 171.5 In the Manipulation group {[}B{]}, the
minimum CT value was 166, the maximum was 1304, the average was 638.1 ±
269.5.

\textbf{Figure 2}. Receiver operating characteristic curve analysis and
area under the curve calculated for manipulation. The maximal CT value
enabled us to predict the simple anastomosis with the AUC (area under
the receiver operating characteristic curve) of 0.96
(p\textless{}0.0001). The cutoff value for the maximal CT value to
predict manipulation was 325 HU (sensitivity 94.1\%, specificity
81.7\%).

\textbf{Figure 3A} . Postoperative 10-year acutual survival rate shows
by the Kaplan-Meier curve. The 5-year and 10-year survival rate were
69.7\% and 38.3\% in all patients.

\textbf{Figure 3B.} The 5-year and 10-year survival rate were 73.3\% and
43.2\% in the Simple group and 47.6\% and 11.2\% in the Manipulation
group.



\begin{CJK}{UTF8}{gbsn}\textbf{Table 1.　Preoperative characteristics}\end{CJK}\selectlanguage{english}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Simple group (n=105)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Manipulation group (n=17)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
p value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Age (y)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
66 \selectlanguage{ngerman}± 14\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
73 \selectlanguage{ngerman}± 6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.07}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Male : Female (n)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
75 : 30\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7 : 10\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.02}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Body weight (kg)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
61.0 \selectlanguage{ngerman}± 13.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
48.2 \selectlanguage{ngerman}± 7.0\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.002}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Hemoglobin (g/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
11.9 \selectlanguage{ngerman}± 1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10.5 \selectlanguage{ngerman}± 1.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.002}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
eGFR (mL/min/1.73~m2)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
65.9 \selectlanguage{ngerman}± 25.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
48.2 \selectlanguage{ngerman}± 20.1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.01}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Hypertension (n, \%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
90 (85.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
12 (70.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.14\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Dyslipidemia (n, \%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
27 (25.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6 (35.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.39\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Smoking (n, \%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
75 (71.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5 (29.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.002}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Diabetes mellitus\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
10 (9.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 (17.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.39\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Arteriosclerosis : Dissection\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
76 : 29\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
17 : 0\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.01}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Main disease\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.33\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Aorta\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
90\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Valve\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Coronary\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
JapanSCORE (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6.6~\selectlanguage{ngerman}±~7.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9.3~\selectlanguage{ngerman}±~10.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.24\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

eGFR: Estimated Glomerular Filtration Rate

CABG: coronary artery bypass grafting



\textbf{Table 2. Replacement range of the aorta and concomitant
procedure}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Simple group (n=105)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Manipulation group (n=17)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
p value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Replacement range\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.004}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Ascending aorta\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
14 (13.3\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9 (52.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Ascending + Arch\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
53 (50.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2 (11.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Arch + Descending aorta\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6 (5.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Aortic root\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5 (4.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Aortic root + Arch\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6 (5.7\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (5.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Descending aorta\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13 (12.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 (17.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Thoracoabdominal aorta\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8 (7.6\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2 (11.8\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Concomitant procedure\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.25\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Valve\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Aortic root\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
CABG\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}



\textbf{Table 3. Perioperative data}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Simple group (n=105)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Manipulation group (n=17)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
p value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Operation time (min)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
601 \selectlanguage{ngerman}± 157\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
532 \selectlanguage{ngerman}± 148\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.09}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
CPB time (min)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
299 \selectlanguage{ngerman}± 87\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
256 \selectlanguage{ngerman}± 94\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\emph{0.06}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Blood loss (g)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8755 \selectlanguage{ngerman}± 452\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
609 \selectlanguage{ngerman}± 310\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.20\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Hospital death (n, \%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2 (1.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (5.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.37\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Stroke (n, \%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (1.0\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.99\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Re-exposure for bleeding (n, \%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2 (1.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (5.9\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.37\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
ICU stay (day)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.0 \selectlanguage{ngerman}± 6.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.6 \selectlanguage{ngerman}± 4.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.71\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Postoperative hospital stay (day)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
22.3 \selectlanguage{ngerman}± 39.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
20.3 \selectlanguage{ngerman}± 14.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.84\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

CPB: cardioPulmonary Bypass

ICU: Intensive Care Unit\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure1/Figure1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure2/Figure2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure3A/Figure3A}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure3B/Figure3B}

\end{center}
\end{figure}

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

