Bulgarian Cardiology · Published 2026-05-05 · DOI 10.3897/bgcardio.32.e189379
Introduction: The term “monster aorta” is a non-formal colloquial expression of advanced aortic disease. Features of the monster aorta phenotype include large aneurysm (> 6 cm), multisegmented involvement, hostile atheroma, chronic dissection, redo surgery, and emergency conditions. Although the literature commonly refers to these cases as “complex aortic pathology”, we propose the descriptive term “Monster Aorta” to emphasize the extraordinary anatomical complexity and technical challenges associated with such procedures. These operations frequently require multi-segment aortic reconstruction and demand management by a dedicated high-volume surgical team experienced in advanced perfusion techniques and cerebral protection strategies. The phrase “monster aorta” appears only rarely in the literature and generally in an informal descriptive context rather than as a formally defi ned clinical entity, illustrating the use of the term as a descriptive characterization of extreme aortic pathology rather than an established diagnostic designation. Objectives: The aim of the study is to establish the defi nition of monster aorta for clinical purposes and to offer best-practice recommendations. Materials and Methods: This is a single-center retrospective observational study of patients who underwent thoracic aortic surgery with monster aorta phenotype. Eight consecutive cases were described individually with respect to cannulation strategies, cerebral protection, frozen elephant trunk (FET) deployment, spinal cord protection, as well as various safeguards and pitfalls. Primary outcome measures were survival and neurologic complications. Results: No hospital mortality occurred and all patient were neurologically intact on discharge. All patients are alive to date. Discussion and Conclusion: This article demonstrates the strategies applied in the surgical treatment of monster aorta pathology in the Department of Cardiac Surgery, Acibadem City Clinic Vitosha Hospital. Based on the favorable postoperative results these surgical strategies seem to be effective and reproducible. The concept of monster aorta is useful in patient’s referral to high-volume centers specialized in thoracic aortic surgery.
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