Analysis of the effect of Preset Cabrol in total arch replacement for type A aortic dissection

Introduction

Type A aortic dissection (TAAD) requires immediate open surgical intervention (1). In China, TAAD patients are notably younger compared to those in European and American countries, with the majority needing Sun’s procedure (2-4). Moreover, the number of large vascular surgeries in China in 2022 exceeded 30,000 cases, with half of these requiring cardiopulmonary bypass (CPB) assistance. However, the complexity of total arch replacement involves hypothermic circulatory arrest (HCA) and prolonged CPB time, which significantly impairs the body’s coagulation function, making hemostasis more difficult and leading to intractable bleeding (5,6). Despite the use of pressure hemostasis and various hemostatic agents, some bleeding instances cannot be fully controlled. Diffuse oozing, suture hole bleeding, and anastomosis site bleeding are common complications (7). As a result, the operation time is considerably prolonged, putting a strain on the surgical team, including surgeons, assistants, anesthetists, perfusionists, and nurses. Suturing and securing the needle in the posterior wall of the aortic root during beating heart surgery are particularly challenging and often require CPB assistance, sometimes necessitating the Cabrol fistula technique as a last resort. During direct suture closure of the transverse pericardial sinus, care must be taken to avoid damaging the left coronary artery. Prolonged hemostasis and extended CPB time continuously deplete the body’s coagulation function, leading to consumption coagulopathy and the need for large blood transfusions (8), which in turn increase the risk of perioperative adverse events related to bleeding and transfusion (9-11). Prognostic risk factors for TAAD include HCA duration, CPB time, cardiac arrest, operation time, and ventilation time (12,13). Thus, strategies aimed at reducing CPB and operation time are crucial. Chen and colleagues (14) suggested routine closure of the transverse pericardial sinus prior to graft implantation, noting that the classical Cabrol autotransfusion technique is not feasible in open ascending aortic repair. The application of the Preset Cabrol technique in total arch replacement for TAAD with abnormal coagulation has been previously reported (15). The results from 203 consecutive cases utilizing the Preset Cabrol technique in Sun’s procedure for TAAD are summarized in this study. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-349/rc).

Methods

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional review board of the General Hospital of the Southern Theater Command (No. 2023010) and individual consent for this retrospective analysis was waived.

Clinical data

Between January 2021 and January 2024, a total of 258 patients [217 males and 41 females, mean age 48.9±12.3 years, mean body mass index (BMI) 26.8±3.7 kg/m²] out of 330 TAAD patients who underwent ascending aortic replacement and Sun’s procedure at the Department of Cardiovascular Surgery, Southern Theater General Hospital in Guangzhou, China, were included. Patients were categorized based on the use of the Preset Cabrol technique, resulting in 203 cases in the preset group and 55 cases in the control group (Figure 1). Diagnosis was confirmed using aortic computed tomography angiography (CTA), bedside echocardiography (ECHO), and relevant laboratory tests, including blood routine, coagulation profile, and complete biochemistry (Table 1).

Figure 1 Flowchart of the case screening for the retrospective study.

Inclusion criteria

(I) Ascending aorta replacement along with Sun’s procedure. (II) Aortic root management involved lifting the aortic valve junction. (III) Interventional recanalization was conducted in cases of visceral malperfusion, with the interventional operation time excluded from the overall sternotomy operation time.

Exclusion criteria

To mitigate or eliminate the impact of aortic root and arch procedures on operation time, the following criteria were applied: (I) type A2 or A3 TAAD involving the aortic root, where procedures such as David, Bentall, or Wheat were employed; (II) patients with untreated arch or those treated using alternative methods, including half-arch replacement or hybrid surgery; (III) patients undergoing concurrent surgical interventions, such as aortofemoral artery bypass, coronary artery bypass, ventricular septal defect repair, mitral valve disease correction, tricuspid valve disease correction, aberrant vertebral artery repair, or aberrant subclavian artery repair.

Operation method

The surgical procedure was consistent across the patient cohort and was performed according to previously documented protocols (13). CPB was established with cannulation of the right atrium, femoral artery, left common carotid artery, right axillary artery, or innominate artery. Aortic clamping was initiated when the nasopharyngeal temperature reached 32 ℃. Depending on the lesion, the proximal aorta was either directly sutured or reinforced using a “sandwich” horizontal mattress technique (16). When the temperature dropped to 26 ℃, femoral artery clamping was implemented, and bilateral antegrade cerebral perfusion (BACP) was initiated with a cerebral perfusion flow rate of 8 mL/(kg·min). After delivering the stented elephant trunk to the descending thoracic aorta, the distal aortic anastomosis was performed first. Upon opening the femoral artery for perfusion, specific anastomotic tension was maintained, and bleeding at the distal anastomosis site was assessed. Subsequently, the proximal aortic anastomosis and treatment of the three branch vessels of the arch were carried out.

Control Group: Following protamine neutralization, medical blood transfusions or additional hemostatic agents were administered according to test results. Hemostatic materials, compression, needle sutures, and other local techniques were actively employed. In cases of persistent or significant bleeding despite these measures, the entire aorta was wrapped. If tension remained high within the wrapped cavity, a Cabrol shunt was performed.

Preset Group: In the preset group, patients underwent an additional modified Cabrol procedure using bovine pericardium (Beijing Balance Medical Technology Co., Ltd., Beijing, China). The surgical technique is demonstrated in Video 1 and Figure 2. The posterior wall of the encapsulating cavity was anastomosed before the vascular anastomosis procedure. The aortic root was lined with pericardium outer pad vascular slices and bovine pericardium strips, or alternatively, with an external pericardium strip. The external bovine pericardium was turned over and sutured to the proximal posterior wall of the autologous aorta (see Figure 3A). In cases of incomplete shearing of the posterior wall of the distal autogenous aorta, it was wrapped and connected through the anastomosis of the stent and artificial vessel. The anterior wall of the encapsulating cavity was then anastomosed to the reserved autologous aortic wall (Figure 3B). Once the anterior wall of the encapsulated cavity was closed, the Cabrol shunt was performed based on the amount of oozing blood, shunting it to the superior vena cava or innominate vein within the right heart system.

Figure 2 Preset Cabrol technique. (A) One group pre-sutured the bovine pericardium to a four-forked artificial blood vessel; (B) vascular replacement and encapsulation cavity anastomosis were completed, where the autologous aortic wall forms an enveloping cavity with the bovine pericardium. The yellow arrow indicates the shunt from the wrapping cavity to the SVC. SVC, superior vena cava.

Figure 3 The wrapping technique of proximal posterior wall and distal anterior wall. (A) The method of wrapping the posterior wall of the proximal artery was preferentially anastomosis with the posterior wall of the autologous aorta by turning the pericardial strip; (B) the method of wrapping the distal anterior wall was to anastomosis the prepositioned bovine pericardium with the prepositioned anterior aortic wall.

Strategies of conservative strategies and observation indicators

The specific methods referenced in this study were based on a previous report (15). Following protamine neutralization, routine administration included 30 IU/kg thrombin and 50 mg/kg fibrinogen. Medical treatment strategies were aligned with the 2017 European Guidelines for the Management of Blood in Adult Patients Undergoing Cardiac Surgery (EACTS/EACTA) and tailored to the specific circumstances of TAAD (17).

The following indicators were observed:

• Patient demographics, medical history, coagulation function indicators, dialysis or creatinine levels ≥4 mg/dL, and results from CTA.
• Surgical details, including the surgical method, operation duration, duration of CPB and circulatory arrest, occurrence of cardiac arrest, hemostasis techniques, number of aortic valve leaflet suspensions, use of the “sandwich” technique for the root, and instances of re-thoracotomy for hemostasis.
• Early postoperative use of packed red blood cells (PRBC) and fresh frozen plasma (FFP), 24-hour postoperative drainage volume, intensive care unit (ICU) stay duration, mechanical ventilation duration, incidence of coma, initiation of bedside hemofiltration, mediastinal infections, 30-day mortality (including automatic discharge), and total hospital costs.
• Mortality during follow-up was documented. Post-discharge, CTA and ECHO were reviewed to assess surgical efficacy.

Statistical analysis

Continuous data were presented as mean (standard deviation) or median (interquartile range), depending on the normality of the distribution. Categorical data were reported as counts and percentages. Baseline characteristics of clinical data related to preoperative and perioperative recovery were compared between the preset and control groups. The Chi-squared test and Fisher’s exact test were used for categorical variables, the independent samples Student’s t-test for parametric continuous variables, and the Mann-Whitney test for nonparametric continuous variables. Survival analyses were estimated using the Kaplan-Meier method with the log-rank test to compare for differences between the groups. All statistical tests were two-tailed, with a significance level set at P<0.05. Statistical analysis was performed using SPSS version 25.0 (SPSS Inc., Chicago, IL, USA).

Results

Colligation condition and the use of blood products during operation and early after operation

Compared to the control group, the preset group showed no significant increase in blocking time, while demonstrating shorter operation and CPB durations, with overall stable data. Blood product transfusion (PRBC, FFP) was reduced, as shown in Table 2.

In the control group, 34 patients (61.8%) received all hemostatic agents and underwent repeated gauze pressure. However, not all bleeding incidents could be prevented. Diffuse oozing, suture hole bleeding, and anastomosis site bleeding occurred in 21 patients (38.2%). Among them, 15 cases (27.3%) were managed with local compressive maneuvers and multiple stitches, while the remaining 6 cases (10.9%) required Cabrol shunting. In the preset group, 163 patients (80.3%) did not require shunting, 36 patients (17.7%) were shunted to the superior vena cava, and the remaining 4 patients (2.0%) were shunted to the innominate veins.

Early postoperative recovery and follow-up

No heart failure induced by excessive shunt flow was observed. Compared to the control group, there was no significant difference in 30-day mortality. However, the preset group demonstrated significantly shorter mechanical ventilation duration and lower total hospitalization costs (Table 3).

A total of 224 patients were followed up, with a mean follow-up duration of 22.1±10.2 months (range, 2.5–39.6 months). Follow-up exams approximately 6 to 12 months later revealed significant absorption of thrombus within the wrapped cavity (Figures 4,5). Thirty-nine deaths occurred in the entire cohort, including patients discharged against medical advice who died within the second postoperative month. There was no statistically significant difference between the two groups (Figure 6). These early and late deaths were not related to the autotransfusion technique for blood lost into the central venous system. No persistent shunting occurred early after surgery or during follow-up, and no complications related to thrombus accumulation were observed.

Figure 4 Male intraoperative and postoperative CTA. The arrows show the wrapping cavity. Thrombus is seen surrounding the lumen and gradually absorbed. (A) Wrapping hemostasis was completed; (B) CTA showed thrombus in the wrapping cavity 20 days after operation; (C) CTA showed thrombus basically absorbed 1 year after surgery. CTA, computed tomography angiography.

Figure 5 Female preoperative and postoperative CTA. The arrows show the wrapping cavity. Thrombus is seen surrounding the lumen and gradually absorbed, and Figure5C,5D showed no significant difference in thrombus absorption in encapsulated lumen. (A) Preoperative cross section of CTA; (B) 20 days after operation; (C) 10 months after surgery; (D) 2 years after surgery. CTA, computed tomography angiography.

Figure 6 The Kaplan-Meier survival curve showing the impact of the Preset Cabrol technique on survival.

Discussion

Sun’s method, proposed by Sun in 2003 (18), involves replacing the entire aortic arch and implanting a stent known as the “elephant trunk”. This procedure typically also includes either partial or complete replacement of the ascending aorta. It is an effective treatment for aortic arch issues and has gained widespread acceptance and use in China. However, not all patients with TAAD require total arch surgery (2). Alternative approaches may involve partial replacement of the ascending aorta or the use of hybrid techniques. While the average age of TAAD patients in Europe and the United States is around 60 years, the average age in China is approximately 50 years (4), with this study showing an average age of 48 years. As a result, approximately 90% of patients undergo Sun’s surgery (3).

Not all TAAD patients undergoing Sun’s surgery require the use of Cabrol diversion to control bleeding. This method, first introduced by Cabrol (19) in 1978 and later refined by Blum and colleagues in 1989 (20), is used as the last resort for persistent bleeding after aortic surgery (21). It primarily addresses leaks from suture needle holes at connection points, particularly in cases where blood clotting issues complicate post-surgery recovery. To manage blood clotting problems prior to TAAD total arch surgery, our center has developed the Preset Cabrol technique, which has shown excellent results in controlling bleeding. Consequently, this study incorporated the modified Cabrol technique into ascending aorta replacement combined with Sun’s surgery and evaluated its outcomes in the short to medium term.

The effectiveness of the Cabrol fistula in controlling persistent bleeding is well established. Raghuram and colleagues successfully managed such bleeding in 17 patients using the Cabrol fistula technique. Among these, 2 patients required exploratory thoracotomy to drain accumulated blood, 2 needed a repeat bypass, and 1 developed septicemia. Except for 2 cases of multiple organ failure and 1 additional death within 30 days, the remaining patients had an average survival of 6.76 years (22). Zhang et al. also confirmed the safety and effectiveness of the Cabrol fistula (23). However, a retrospective analysis of a registry study by Liu et al. (24), which reviewed 3,283 patients with TAAD between 2016 and 2022, found that 2,201 (67%) of these patients underwent the Cabrol shunt. The overall operative mortality rate was 6.6% (146/2,201 in the Cabrol shunt group and 71/1,082 in the non-Cabrol shunt group). The study used mortality as the endpoint and therefore did not recommend the routine use of the Cabrol technique in aortic surgery. However, the Cabrol shunt group in this study had more severe aortic dissection cases, including high-risk bleeding patients, such as those taking oral anticoagulants or antiplatelet drugs preoperatively (24). Additionally, surgeries in the Cabrol shunt group were more complex, with a higher rate of double arch replacement compared to the non-Cabrol group, contributing to the higher mortality rates. These patients, despite having higher mortality risks, were reduced to the level of ordinary aortic dissection patients due to the wrapping technique; otherwise, they would likely have died, as previous study has confirmed (25). The lack of statistical significance in mortality between the two groups in this study may be attributed to the following factors: (I) after the introduction of the preset Cabrol technique, it became highly favored by operating room staff, leading to its preference in most subsequent cases, which resulted in a relatively smaller sample size for the control group; (II) to minimize overtime for staff and avoid potential “weekend effects” on surgeries (26,27), the preset Cabrol technique was often used for surgeries conducted during non-working hours (7 pm–5 am or weekends).

In the control group, the Cabrol fistula procedure was not part of the initial surgical plan. As a result, performing the technique after completing the primary repair necessitated reconfiguring the wrapping sutures, making the procedure more technically demanding and time-consuming. In contrast, in the Preset group, the Cabrol fistula was integrated into the surgical plan from the outset, allowing for a more streamlined approach and reduced operative time. This may have lowered the threshold for employing the Cabrol fistula in the Preset group. However, the difference in the rate of Cabrol fistula creation between the two groups (10.9% vs. 17.8%) was not statistically significant. Moreover, because shunt flow through the Cabrol fistula generally decreases over the short term until eventual thrombosis occurs, its impact on overall patient outcomes is likely minimal. Other results of this study align with previous reports on the use of the preset technique in patients with severe preoperative coagulation abnormalities in aortic dissection. This technique helps reduce surgical and bypass times, as well as decrease intraoperative and postoperative blood transfusion requirements (15). In summary, the additional few minutes of aortic cross-clamp time introduced by the preset technique in Sun’s surgery are acceptable, as they reduce the time needed for additional sutures at the root and posterior wall reinforcement. Our adoption of the stop-jump flip-flop pericardium with autologous aortic anastomosis for posterior wall wrapping requires no specialized suture skills, resulting in more stable surgical times.

Regarding the concern of whether adding grafts increases the infection risk (28), no significant difference in mediastinal infection rates was observed between the two groups. Early postoperative ultrasound evaluations showed that the encapsulated annular cavity gradually closed with thrombus accumulation within hours to days, without any complications arising from thrombus accumulation (22), consistent with findings by Chen (14). Follow-up CTA of the aorta 20–35 days post-surgery confirmed no pseudoaneurysm formation in the wrapped cavity for patients in both the experimental and control groups, with complete thrombosis closure achieved.

It is important to note that surgical hemostasis should be meticulously performed, paying close attention to technical details, especially if there is spurting bleeding. Such bleeding should be managed using precise vascular anastomosis techniques. The Cabrol technique is reserved for managing diffuse oozing only. Therefore, careful attention to technical details in vascular anastomosis is crucial for preventing bleeding.

Conclusions

Historically, many surgeons were hesitant to employ the Cabrol fistula procedure, often reserving it as the last resort for managing stubborn hemorrhages. Unfortunately, this life-saving technique was relegated to desperate measures. However, we had taken a proactive approach by incorporating this technique into surgeries for patients with TAAD, seamlessly integrating the Preset Cabrol technique into Sun’s surgical procedures. Our findings indicate that this technique reduces CPB and operative times, resulting in decreased hospitalization costs. Importantly, during both the early postoperative and follow-up periods, we observed no complications from continuous shunting of encapsulated effusion or thrombosis. Thus, the application of the Preset Cabrol technique in Sun’s surgeries demonstrates excellent hemostatic efficacy and warrants widespread adoption. Furthermore, in the next phase, we propose covering the starting point of the 4-branch artificial vessel with pericardium or cardiovascular patches before factory release, creating a pre-assembled product. This innovation eliminates the need for intraoperative suturing of the pericardium, as shown in Figure 1A.

Study limitations

Firstly, this study is a single-center retrospective analysis, and the allocation of groups lacked randomization. Secondly, both the experimental and control groups had relatively small sample sizes, particularly the control group, which consisted of only 55 cases. Additionally, the Preset Cabrol technique was predominantly used in more severe cases, such as those involving malperfusion syndrome (MPS) or cardiac tamponade, yet the samples were not matched by propensity score. Thirdly, variations in operator expertise may have influenced the study outcomes, which could pose challenges to the generalizability of the results, particularly in multicenter studies or broader applications. Furthermore, this study lacks midterm and long-term follow-up data. Finally, the exclusion of patients undergoing approaches other than Sun’s surgery combined with ascending aorta replacement may introduce bias in surgical time and research findings. However, it is important to note that the Cabrol technique is particularly effective for managing bleeding in aortic root surgery (29). Therefore, further investigation is necessary to assess the hemostatic efficacy of the Preset Cabrol technique across various approaches for aortic root management.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-349/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-349/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-349/prf

Funding: This study was supported by the Guangdong Medical Science and Technology Research Foundation Project (No. C2022135); Guangdong Provincial Bureau of Traditional Chinese Medicine Research Project (No. 20251497); Guangzhou Science and Technology Program Project (No. 2025A03J3250).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-349/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional review board of the General Hospital of the Southern Theater Command (No. 2023010) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Carrel T, Sundt TM 3rd, von Kodolitsch Y, et al. Acute aortic dissection. Lancet 2023;401:773-88. [Crossref] [PubMed]
2. Malaisrie SC, Szeto WY, Halas M, et al. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021;162:735-758.e2. [Crossref] [PubMed]
3. Zhao R, Qiu J, Dai L, et al. Current Surgical Management of Acute Type A Aortic Dissection in China: A Multicenter Registry Study. JACC Asia 2022;2:869-78. [Crossref] [PubMed]
4. Sun LZ, Li JR. Progress and challenge of Stanford type A aortic dissection in China. Zhonghua Wai Ke Za Zhi 2017;55:241-4. [Crossref] [PubMed]
5. Guan XL, Wang XL, Liu YY, et al. Changes in the Hemostatic System of Patients With Acute Aortic Dissection Undergoing Aortic Arch Surgery. Ann Thorac Surg 2016;101:945-51. [Crossref] [PubMed]
6. Li J, Wang X, Zhu K, et al. Perioperative dynamic changes of systemic inflammatory response, gut injury, and hypoxemia in patients with acute type-A aortic dissection: an observational case-control study. J Thorac Dis 2025;17:1054-63. [Crossref] [PubMed]
7. Lee JH. Prevention and management of difficult hemostasis in acute type A aortic dissection repair. Asian Cardiovasc Thorac Ann 2023;31:15-9. [Crossref] [PubMed]
8. Liu Y, Han L, Li J, et al. Consumption coagulopathy in acute aortic dissection: principles of management. J Cardiothorac Surg 2017;12:50. [Crossref] [PubMed]
9. Gupta R. Red Blood Cell Transfusion and Cardiac Surgery-Associated Acute Kidney Injury. JACC Basic Transl Sci 2022;7:639-41. [Crossref] [PubMed]
10. Chen FT, Chou AH, Wu VC, et al. Effect of massive blood transfusion on late outcomes after surgical repair of acute type A aortic dissection. Medicine (Baltimore) 2019;98:e17816. [Crossref] [PubMed]
11. Pfeiffer P, Buchholz V, Probst C, et al. Transfusion and coagulation management in acute type A aortic dissection. Arch Cardiovasc Dis 2025;118:365-73. [Crossref] [PubMed]
12. Zhu X, Wang J, Chong H, et al. Analysis of risk factors for postoperative mortality in acute type A aortic dissection patients under different critical levels. Sci Rep 2023;13:8107. [Crossref] [PubMed]
13. Abukhodair A, Alqarni MS, Alzahrani A, et al. Risk Factors for Postoperative Infections in Cardiac Surgery Patients: A Retrospective Study. Cureus 2023;15:e43614. [Crossref] [PubMed]
14. Chen LW, Wu XJ, Dai XF. Transverse Pericardial Sinus Closure in Acute Type A Aortic Dissection Operation. Ann Thorac Surg 2017;104:e351-3. [Crossref] [PubMed]
15. Cai Z, Yan T, Zhang B, et al. Analysis of the hemostatic effect of preset wrapping technique for type A aortic dissection with abnormal coagulation. J Thorac Dis 2024;16:1223-33. [Crossref] [PubMed]
16. Tang Y, Liao Z, Han L, et al. Long-term results of modified sandwich repair of aortic root in 151 patients with acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2017;25:109-13. [Crossref] [PubMed]
17. Erdoes G, Ahmed A, Kurz SD, et al. Perioperative hemostatic management of patients with type A aortic dissection. Front Cardiovasc Med 2023;10:1294505. [Crossref] [PubMed]
18. Sun L, Qi R, Zhu J, et al. Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch? Circulation 2011;123:971-8. [Crossref] [PubMed]
19. Cabrol C, Pavie A, Mesnildrey P, et al. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91:17-25.
20. Blum M, Panos A, Lichtenstein SV, et al. Modified Cabrol shunt for control of hemorrhage in repair of type A dissection of the aorta. Ann Thorac Surg 1989;48:709-11. [Crossref] [PubMed]
21. Vogt PR, Akinturk H, Bettex DA, et al. Modification of surgical aortoatrial shunts for inaccessible bleeding in aortic surgery -- modification of the Cabrol-shunt technique. Thorac Cardiovasc Surg 2001;49:240-2. [Crossref] [PubMed]
22. Raghuram A, Kalyanasundaram A, Babcock M, et al. Long-term follow-up of Cabrol fistula for uncontrollable bleeding: A life-saving procedure. JTCVS Tech 2023;21:1-6. [Crossref] [PubMed]
23. Zhang H, Wu X, Fang G, et al. Is it justified to apply a modified Cabrol fistula in surgical repair of acute type A aortic dissection? J Thorac Cardiovasc Surg 2019;158:1307-1314.e2. [Crossref] [PubMed]
24. Liu H, Sun BQ, Qian SC, et al. Contemporary use and outcome of Cabrol shunt in type A aortic dissection surgery: insight from China 5A study. Open Heart 2023;10:e002465. [Crossref] [PubMed]
25. Toole JM, Stroud MR, Ikonomidis JS. Salvage periaortic pericardial baffle equalizes mortality in bleeding patients undergoing aortic surgery. J Thorac Cardiovasc Surg 2014;148:151-5. [Crossref] [PubMed]
26. Toh S, Yew DCM, Choong JJ, et al. Acute type A aortic dissection in-hours versus out-of-hours: A systematic review and meta-analysis. J Card Surg 2020;35:3432-9. [Crossref] [PubMed]
27. Takahashi T, Yoshino H, Akutsu K, et al. In-Hospital Mortality of Patients With Acute Type A Aortic Dissection Hospitalized on Weekends Versus Weekdays. JACC Asia 2022;2:369-81. [Crossref] [PubMed]
28. Khaladj N, Juchem G, Hagl C, et al. Modified Cabrol shunt by means of a saphenous vein graft after redo aortic root surgery due to a graft infection. Eur J Cardiothorac Surg 2014;45:583. [Crossref] [PubMed]
29. Ohira S, Cameron DE, Lansman SL, et al. Complex Bentall Operation: Clinical Pearls to Standardize the Procedure. Ann Thorac Surg 2025;119:744-54. [Crossref] [PubMed]