2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

One-stage or two-stage elective coronary artery bypass graft surgery and abdominal aortic aneurysm open repair in low and moderate cardiac surgical risk patients

ObjectivesCoronary artery disease (CAD) and abdominal aortic aneurysm (AAA) are common arterial pathologies that might occur simultaneously; however, there is not enough evidence about the optimal strategy for patients with concomitant indications of coronary artery bypass grafting (CABG) and open repair of the AAA (AAOR). This study aims to present the outcomes in low and moderate cardiac surgical risk patients who underwent one-stage or two-stage elective CABG and AAOR in a middle-income country.MethodsAn observational, retrospective case series study was conducted. Patients who had low and moderate cardiac surgical risk (less than 8% mortality risk on the STS score) and had the concomitant indication for CABG and AAOR between December 2005 and August 2021 were included. Patients were assigned to one of three strategies: Group 1 underwent one-stage surgery for CABG and AAOR, Group 2 underwent two-stage surgery within the same in-patient stay, and Group 3 underwent two-stage surgery in a new in-patient stay within 6 months.ResultsTwenty seven, patients with simultaneous requirements of CABG and AAOR were identified, with a mean age of 69.5 ± 6.1 years and 92.6% were male. The most common comorbidities were hypertension at 77.8% and dyslipidemia at 55.6%. The average mortality risk calculated by the STS score was 2.09% ± 1.53%. In Group 1 (n = 9), 1/9 had in-hospital mortality and no reinterventions were needed. In Group 2 (n = 10), 1/10 had in-hospital mortality, and the most common postoperative complication was acute kidney injury 2/10. Furthermore, 2/10 required a reintervention. In Group 3 (n = 8), no in-hospital mortality was present, however, complications such as sepsis, atrial fibrillation, and acute kidney injury occurred in 2/8 patients each, and 2/8 required a reintervention.ConclusionPatients with CAD and AAA that need a concomitant surgical correction with CABG and an AAOR are uncommon in contemporary practice, given the advances in endovascular therapy. When indicated, one-stage surgery can be performed in patients with low cardiac surgical risk, proper patient selection plays a fundamental role and might be performed in experienced centers. However, two-staged surgeries at the same or different inpatient stay may be considered for asymptomatic AAA with close monitoring during the postoperative period. These findings can hold significance for addressing sociodemographic barriers in low and middle-income countries. More robust and extensive studies are needed to make clear comparisons between the different strategies.

Anesthesia Management for the Personalized External Aortic Root Support (PEARS) Procedure: A Single-Center Experience

OBJECTIVE

To delineate anesthesia management during the personalized external aortic root support (PEARS) procedure, with a focus on the use of multimodal monitoring and deliberate profound hypotension.

DESIGN

A single-center retrospective cohort study.

SETTING

Tertiary academic hospital.

PARTICIPANTS

Patients undergoing the PEARS procedure due to aortic aneurysm.

INTERVENTIONS

None.

METHODS

Patient characteristics and anesthesia management are described, with particular emphasis on multimodal hemodynamic, cerebral monitoring, and transesophageal echocardiography during the deliberate profound hypotension phase during the isolated PEARS procedure.

RESULTS

SEVENTY-THREE: patients underwent an isolated PEARS procedure in an academic hospital in The Netherlands between January, 2018, and December, 2023. Fifty-six patients were male (72.2%), and the mean patient age was 38 ± 15.7 years. Five patients required conversion to cardiopulmonary bypass. There were no in-hospital deaths, myocardial infarction, stroke, major bleeding, reoperation for any cause, prosthesis infection, or postoperative delirium. Postoperative atrial fibrillation occurred in 11 patients (15.1%). The mean duration of intensive care unit admission was 1.3 days, and the mean hospital length of stay was 7.6 days. All procedures were performed by a single surgeon.

CONCLUSIONS

The PEARS procedure appears to be a viable alternative for preventive replacement of the aorta in selected patients with aortic aneurysms. Anesthesia is safe; in particular, profound deliberate hypotension can be used without relevant complications using multimodal monitoring, with electroencephalographic burst suppression as the guiding factor for cerebral perfusion. As published by other groups, PEARS has excellent outcomes in experienced centers.

Ketorolac in the perioperative management of acute type A aortic dissection: a randomized double-blind placebo-controlled trial

BACKGROUND

Acute Type A Aortic Dissection (aTAAD) is a severe and life-threatening condition. While animal studies have suggested that ketorolac could slow the progression of aortic aneurysms and dissections, clinical data on its efficacy in aTAAD patients remain limited. This study seeks to evaluate the safety and effectiveness of ketorolac in this patient group.

METHODS

Patients were randomly assigned to receive either ketorolac or a placebo (0.9% saline). Treatment began at least 2 h prior to surgery (60 mg ketorolac or 2 ml saline administered once intramuscularly) and continued for 48 h post-surgery (30 mg ketorolac or 1 ml saline administered intramuscularly twice daily). The primary endpoints included assessing the safety and efficacy of ketorolac in improving the prognosis of aTAAD, focusing on mortality and organ malperfusion syndrome. Secondary endpoints included drug-related adverse events, blood test results, and other postoperative outcomes.

RESULTS

Of 179 patients who underwent aTAAD repair, 110 met the inclusion criteria and were randomized into two groups of 55. One patient discontinued the intervention due to erythroderma on the first postoperative day, leaving 54 patients in the ketorolac group and 55 in the placebo group for analysis. No significant differences were found in the primary endpoints. However, the ketorolac group showed lower intraoperative bleeding (median: 1.8 L vs. 2.0 L, P = 0.03), shorter intensive care unit (ICU) stays (median: 6.5 days vs. 8 days, P = 0.04), and lower total hospital costs (median: ¥170,430 vs. ¥187,730, P = 0.03).

CONCLUSIONS

Short-term ketorolac therapy did not alter the primary outcome but was associated with reduced intraoperative bleeding, shorter ICU stays, and potentially lower hospitalization costs. It demonstrates safety and a certain degree of effectiveness during the perioperative period. These findings suggest that ketorolac could be a viable option for perioperative management in patients with aTAAD.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Register ( www.chictr.org.cn , No: ChiCTR2300074394).

Imaging-based biomechanical parameters for assessing risk of aortic dissection and rupture in thoracic aortic aneurysms

OBJECTIVES

Imaging-based methods of measuring aortic biomechanics may provide superior and a more personalized in vivo risk assessment of patients with thoracic aortic aneurysms compared to traditional aortic size criteria such as maximal aortic diameter. We aim to summarize the data on in vivo imaging techniques for evaluation of aortic biomechanics.

METHODS

A thorough search of literature was conducted in MEDLINE, EMBASE and Google Scholar for evidence of various imaging-based biomechanics techniques. All imaging modalities were included. Data involving preclinical/animal models or exclusively focussed on abdominal aortic aneurysms were excluded.

RESULTS

The various imaging-based biomechanical parameters can be divided into categories of increasing complexity: strain-based, stiffness-based and computational modelling-derived. Strain-based and stiffness-based parameters are more simply calculated and can be derived using multiple imaging modalities. Initial studies are promising towards linking these parameters with clinically relevant end-points, including aortic dissection, though work is required for standardization. Computationally derived parameters provide detail of stress exerted on the aortic wall with great spatial resolution. However, they are highly dependent on the assumptions applied to the models, such as material properties of the aortic wall.

CONCLUSIONS

Imaging-based aortic biomechanics represent a major technical advancement for personalized in vivo risk stratification of patients with ascending thoracic aortic aneurysm. The next steps in clinical translation require large-scale validation of these markers towards predicting aortic dissections and comparison against the gold standard ex vivo aortic biomechanics as well as development of a user-friendly, low-cost algorithm that can be widely adopted.

Reconstruction of the isolated left vertebral artery in total aortic arch replacement for type A aortic dissection via a single upper right hemisternotomy approach

OBJECTIVES

The isolated left vertebral artery (ILVA) is a rare congenital abnormality of the branches of the aortic arch. Its presence can influence both the surgical procedure and the prognosis of total aortic arch replacement. The goal of this study was to assess the early postoperative outcomes of ILVA reconstruction performed during total aortic arch replacement via a single upper right hemisternotomy approach.

METHODS

From October 2018 to March 2024, patients diagnosed with type A aortic dissection who underwent total aortic arch replacement via a single upper right hemisternotomy at the General Hospital of the Northern Theater Command were included. Based on the presence of ILVA, the patients were divided into the ILVA group and the control group. Patients in the ILVA group underwent intraoperative ILVA reconstruction, and relevant perioperative clinical data were collected and analysed. Inverse probability of treatment weighting was applied to balance the preoperative baseline data.

RESULTS

A total of 516 patients were included in the study. Of these, 34 patients were in the ILVA group, which included 27 males (79.4%) with a mean age of 48.9 ± 12.9 years; the remaining 482 patients were assigned to the control group, which included 360 males (74.7%) with a mean age of 50.5 ± 10.9 years. Following adjustment using the inverse probability of treatment weighting, the incidence of paraplegia was significantly lower in the ILVA group than in the control group (0% vs 2.14%, P = 0.003). Furthermore, the incidence of stroke (3.38% vs 6.55%, P = 0.354) and of in-hospital death (3.23% vs 5.58%, P = 0.454) was similar in both groups.

CONCLUSIONS

The research indicates that ILVA reconstruction during total aortic arch replacement via a single upper right hemisternotomy effectively preserved ILVA patency and resulted in excellent early outcomes. Statistically, the incidence of postoperative paraplegia was significantly lower compared to the that in the control group, and no significant differences were observed in deaths or other complications between the 2 groups.

CLINICAL REGISTRATION NUMBER

The study was approved by the Ethics Committee of the General Hospital of the Northern Theater Command, Shenyang City, China [Y(2024)188].

Pathobiology of Aortic Aneurysms and Dissections: Synthesis of Recent Investigations and Evolving Insights

The pathobiology of aortic disease is linked to aortic region: atherosclerosis for abdominal aorta, primary medial degeneration or aortitis for ascending thoracic aorta, and all causes for descending thoracic aorta and thoracoabdominal lesions. The pathogenesis of aortic dissection involves damage of the outer media from impaired perfusion from dysfunctional vasa vasorum, formation of discrete foci of disrupted vascular smooth muscle cell-elastic fiber extension-contractile units, and imbalance of radial sheer stress across the aortic wall, thereby creating an intimal tear and linear dissection. Thoracic aortic aneurysms develop from the chronic progression of medial degeneration coupled with the weakening of the remodeled adventitia, allowing for aortic dilatation. Precipitating factors include hypertension and mutations of genes regulating the vascular smooth muscle cell-elastic fiber extension-contractile units. Criteria are presented for distinguishing genetic from acquired causes of thoracic aortic aneurysms and dissections, with important implications for therapeutic and surgical decisions in the care of these patients.

Admission pulse pressure and in-hospital mortality in type A acute aortic dissection: result from a Chinese study in stable patients on admission

OBJECTIVES

In recent years, several epidemiologic studies have shown that pulse pressure (PP) is a powerful predictor of mortality from many cardiovascular diseases. However, few studies have reported the association between PP and adverse events during hospitalization in patients with type A acute aortic dissection (TAAAD). The aim of this study was to evaluate the relationship between admission PP and in-hospital all-cause mortality, in patients with TAAAD of relatively stable patients.

METHODS

Patients with TAAAD of relatively stable patients admitted from January 2015 to December 2021 were included and divided into four groups according to the PP values measured at the time of admission: reduced group (PP ≤ 40 mmHg), normal group (40 < PP ≤ 56 mmHg), mildly elevated group (56 < PP ≤ 75 mmHg), and significantly elevated group (PP > 75 mmHg). A multivariate binary logistic regression model was constructed, plotted using nomogram and evaluated with ROC curve.

RESULTS

Admission PP and in-hospital all-cause mortality showed a "J-curve" correlation and in-hospital all-cause mortality was significantly higher in the significantly elevated group and reduced group (P = 0.002), respectively. Multivariate binary logistic regression analysis showed that significantly elevated PP (PP > 75 mmHg) (P < 0.001) and reduced PP (P = 0.043), D-dimer (P < 0.001), ascending aortic diameter (P = 0.037), Abdominal visceral vessels involved (P = 0.017), and coronary atherosclerosis (P = 0.003) and emergent surgery (P < 0.001) were independent predictive factors for in-hospital all-cause mortality. The AUC of ROC plotted was 0.827 (95% CI 0.774-0.880).

CONCLUSIONS

Our findings demonstrated a "J-curve" association of admission PP with in-hospital all-cause mortality in TAAAD. Significantly elevated and reduced admission PP, D-dimer, ascending aortic diameter and coronary atherosclerosis were independent risk factors for in-hospital all-cause mortality in patients with TAAAD, and emergent surgery was a protective factor.

Prediction Model of in Hospital Death for Stanford Type A Aortic Dissection Based on a Meta-Analysis of 24 Cohorts

Patients with Stanford type A aortic dissection (TAAD) have high postoperative mortality. This study aimed to develop a prediction model for in-hospital death after surgery in patients with TAAD. The derivation cohort came from a meta-analysis. Major risk factors were counted. The corresponding hazard ratio was reported to establish a prediction model for in-hospital death in patients with TAAD. Validation cohorts from 2 centres were used to evaluate the prediction model. The meta-analysis included 24 cohort studies with a total of 11,404 patients and 1,554 patients died early after surgery. Risk factors for the prediction model included age, body mass index, smoking, coronary heart disease, preoperative stroke, shock, preoperative cardiopulmonary resuscitation, pericardial tamponade and malperfusion. Patients with TAAD admitted to the First and the Fourth Hospital of Hebei Medical University between January 2020 and June 2024 were retrospectively collected. Patients from the 2 hospitals constituted validation cohorts A (n = 262) and B (n = 138). Risk scores were calculated for model validation and the prediction model demonstrated better differentiation for validation cohort A, with an area under the curve of 0.886 (95% confidence interval 0.842 to 0.931). This study established a simple risk prediction model, including 13 risk factors, to predict in-hospital death in patients with TAAD. However, multicenter data is still needed to evaluate the prediction accuracy of the model.

Special considerations in assisted reproductive technology for patients with cardiovascular disease

Many individuals with cardiovascular disease can benefit from the availability of assisted reproductive technologies (ARTs) for family building. Its use for this population may be because of underlying infertility, a need for fertility preservation before disease worsening or heart transplant, a genetic cardiac condition they believe to avoid passing to offspring, or the need to use a gestational surrogate in the setting of cardiovascular contraindications to pregnancy. Cardiovascular disease exists on a spectrum, from mild and common diseases that pose minimal threat to maternal health during pregnancy to severe and rare diseases with a high risk of morbidity and maternal mortality if ART or pregnancy is pursued. In this review, we characterize the varying cardiovascular diseases from the lens of the reproductive-aged patient undergoing ART. We classify the necessary steps in the pre-ART evaluation from the multidisciplinary team, discuss risk stratification before ART treatment and possible subsequent pregnancy, and offer specific evidence-based guidance on the care of these patients during the in vitro fertilization and embryo transfer cycles.

Cardio-obstetrics in the Cardiac Intensive Care Unit: An Introductory Guide

The care of the cardio-obstetric population in the cardiac intensive care unit is challenging due to limited data in this patient population. Optimal care requires a broad multidisciplinary team of experts such that both maternal and fetal health are fully supported. A deep understanding of the interplay between the hemodynamics of pregnancy and the clinical manifestations of varied cardiac disease states is essential. The assessment, diagnostic testing, and treatment of patients who are pregnant require special consideration, especially as teams consider pharmacological and invasive therapies. Complex ethical decisions often arise and therapies may be limited by federal and state policy, which adds an additional layer of complexity. This review serves as an introductory guide to cardio-obstetric care in the cardiac intensive care unit.

Branched Endovascular Repair of Aortic Recoarctation and Postcoarctation Descending Thoracic Aortic Aneurysm With the Off-the-Shelf Thoracic Branch Endoprosthesis

Recurrent coarctation of the aorta (reCoA) can be treated via redo surgical or endovascular means with the latter option providing a shorter hospitalization, expedient recovery, and a lower incidence of early morbidity and mortality. A common barrier to endovascular repair with standard thoracic endografts is the proximity of the left subclavian artery (LSA) to the reCoA which has previously necessitated adjunctive open revascularization or additional off-label endovascular techniques. This case describes percutaneous endovascular repair of postsurgical reCoA and a poststenotic descending thoracic aortic aneurysm with an off-the-shelf thoracic branched endograft incorporating the LSA with successful resolution of aortic pressure gradient and complete aneurysm exclusion.Clinical ImpactThis case highlights the use of a commercially available, off-the-shelf endograft to treat thoracic aortic coarctation and associated aortic aneurysm. The paper highlights unique technical points for use of the Gore Thoracic Branch Endoprosthesis in the off-label treatment of thoracic aortic coarctation which is an ideal endovascular option for lesions in proximity to the left subclavian artery.

Practical approach to measuring vessels and reporting z-scores in children

Heart size and vessel diameters naturally increase with a child's growth, development, and needs. Measuring the size of blood vessels and tracking their growth have become a common practice among pediatric imaging specialists. Practitioners use tools like z-scores to standardize measurements against reference values that account for age, sex, and/or body size and habitus and help determine if vascular measurements deviate from what is expected in a healthy population. In this article, we review measurement techniques of significant vascular regions of interest in children covering "how to measure," "where to measure," and "sources of measurement errors." We also go over the concept of reporting z-scores in children with a review of the available literature and commonly used pediatric z-score calculators.

Non-canonical splice variants in thoracic aortic dissection cases and Marfan syndrome with negative genetic testing

Individuals with heritable thoracic aortic disease (HTAD) face a high risk of deadly aortic dissections, but genetic testing identifies causative variants in only a minority of cases. We explored the contribution of non-canonical splice variants (NCVAS) to thoracic aortic disease (TAD) using SpliceAI and sequencing data from diverse cohorts, including 551 early-onset sporadic dissection cases and 437 HTAD probands with exome sequencing, 57 HTAD pedigrees with whole genome sequencing, and select sporadic cases with clinical panel testing. NCVAS were identified in syndromic HTAD genes such as FBN1, SMAD3, and COL3A1, including intronic variants in FBN1 in two Marfan syndrome (MFS) families. Validation in the Penn Medicine BioBank and UK Biobank showed enrichment of NCVAS in HTAD-associated genes among dissections. These findings suggest NCVAS are an underrecognized contributor to TAD, particularly in sporadic dissection and unsolved MFS cases, highlighting the potential of advanced splice prediction tools in genetic diagnostics.

Computational model of coarctation of the aorta in rabbits suggests persistent ascending aortic remodeling post-correction

Coarctation of the aorta (CoA) is a common congenital cardiovascular lesion that presents as a localized narrowing of the proximal descending aorta. While improvements in surgical and catheter-based techniques have increased short-term survival, there is a high long-term risk of hypertension and a reduced average lifespan despite correction. Computational models can be used to estimate aortic remodeling and peripheral vascular compensation, potentially serving as key tools in developing a mechanistic understanding of the interplay between pre-treatment dynamics, post-treatment recovery, and long-term hypertension risk. In this study, we developed a lumped-parameter model of the heart and circulation to simulate CoA. After fitting model parameters using imaging and catheterization data from healthy rabbits, we then used the model to estimate differences in ascending aortic compliance and peripheral resistance between the healthy group and rabbits with both untreated and corrected CoA using their imaging and catheterization data. CoA was defined by the current putative clinical treatment threshold (a pressure gradient > 20 mm Hg). Model inputs were fitted such that outputs matched reported stroke volume, ejection fraction, systolic and diastolic aortic pressure, peak aortic flow, mean and peak blood pressure gradients, and upper-to-lower body flow split, with all results falling within one standard deviation of the data for all groups. In the untreated CoA and corrected simulations, a decrease in ascending aortic compliance was necessary to match reported hemodynamics. This suggests exposure to a pressure gradient > 20 mm Hg results in vascular remodeling that persists after repair, a process strongly correlated with hypertension.

Prognostic Value of Biomarkers in Acute Aortic Dissection: Analysis of Clinical Outcomes and Mortality

Introduction: Acute aortic dissection (AAD) is a severe condition requiring immediate diagnosis and treatment to reduce high mortality rates. This study investigates laboratory markers that may support the diagnostic process and predict surgical outcomes and mortality in AAD patients. Materials and Methods: This retrospective study analyzed data from 85 patients diagnosed with AAD in an emergency setting. Patients over 18 years of age with a diagnosis of acute dissection were included. Key laboratory and clinical parameters were examined to determine their association with mortality and the likelihood of surgical intervention. Results: The study found that younger patients were more likely to undergo surgery, while parameters such as white blood cells (WBCs), neutrophil, and lymphocyte counts were elevated in those undergoing surgery. Mortality predictors included elevated mean platelet volume (MPV), low pH, bicarbonate (HCO3), and base deficit levels. Each unit increase in MPV was associated with a threefold increase in mortality risk, and DeBakey Type 1 patients exhibited the highest MPV levels. Discussion: WBC and MPV values were linked with surgical and mortality outcomes, respectively. Blood gas analysis parameters, particularly HCO3 and base deficit levels, were significant mortality predictors, underscoring the importance of metabolic markers in AAD assessment. The findings suggest that incorporating these laboratory parameters into diagnostic and treatment decisions could improve AAD management.

Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology

COLLABORATORS

Larry A. Allen, MD, MHS, FAHA, FACC; Mats Börjesson, MD, PhD, FACC; Alan C. Braverman, MD, FACC; Julie A. Brothers, MD; Silvia Castelletti, MD, MSc, FESC; Eugene H. Chung, MD, MPH, FHRS, FAHA, FACC; Timothy W. Churchill, MD, FACC; Guido Claessen, MD, PhD; Flavio D'Ascenzi, MD, PhD; Douglas Darden, MD; Peter N. Dean, MD, FACC; Neal W. Dickert, MD, PhD, FACC; Jonathan A. Drezner, MD; Katherine E. Economy, MD, MPH; Thijs M.H. Eijsvogels, PhD; Michael S. Emery, MD, MS, FACC; Susan P. Etheridge, MD, FHRS, FAHA, FACC; Sabiha Gati, BSc (Hons), MBBS, PhD, MRCP, FESC; Belinda Gray, BSc (Med), MBBS, PhD; Martin Halle, MD; Kimberly G. Harmon, MD; Jeffrey J. Hsu, MD, PhD, FAHA, FACC; Richard J. Kovacs, MD, FAHA, MACC; Sheela Krishnan, MD, FACC; Mark S. Link, MD, FHRS, FAHA, FACC; Martin Maron, MD; Silvana Molossi, MD, PhD, FACC; Antonio Pelliccia, MD; Jack C. Salerno, MD, FACC, FHRS; Ankit B. Shah, MD, MPH, FACC; Sanjay Sharma, BSc (Hons), MBChB, MRCP (UK), MD; Tamanna K. Singh, MD, FACC; Katie M. Stewart, NP, MS; Paul D. Thompson, MD, FAHA, FACC; Meagan M. Wasfy, MD, MPH, FACC; Matthias Wilhelm, MD.

This American Heart Association/American College of Cardiology scientific statement on clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities or diseases is organized into 11 distinct sections focused on sports-specific topics or disease processes that are relevant when considering the potential risks of adverse cardiovascular events, including sudden cardiac arrest, during competitive sports participation. Task forces comprising international experts in sports cardiology and the respective topics covered were assigned to each section and prepared specific clinical considerations tables for practitioners to reference. Comprehensive literature review and an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.

Nationwide analysis of the relationship between low ambient temperature and acute aortic dissection-related hospitalizations

AIMS

Acute aortic dissection (AAD) is a life-threatening cardiovascular emergency. Therefore, identifying modifiable risk factors for AAD is of great public health significance. An association between ambient temperature (AT) and AAD has been reported; however, not all findings have been elucidated. This study examined the association between AAD-related hospitalization and AT using data from the Japanese Registry of All Cardiac and Vascular Diseases Diagnostic Procedure Combination (JROAD-DPC), which is a nationwide claims-based database.

METHODS AND RESULTS

This nationwide time-stratified case-crossover study evaluated data of hospitalized patients with AAD from 1119 certified hospitals between 2012 and 2020 using the JROAD-DPC database. Conditional logistic regression and distributed lag non-linear models were used to investigate the association between average daily temperature and AAD-related hospitalization. Among the 96 812 cases analysed, the exposure-response curve between AT and AAD-related hospitalization showed an increase in the odds ratio for lower temperatures, with a peak at time -10°C (odds ratio: 2.28, 95% confidence interval: 1.92-2.71, compared with that at 20°C). The effects of temperature on lag days 0 and 1 were also significant.Stratified analyses showed a greater association between AT and AAD-related hospitalization for the following variables: older age (≥75 years), female sex (44.4%, the mean age ± SD was 76 ± 12 years), low body mass index (<22), winter season, and warmer regions.

CONCLUSION

Low AT is associated with an increased risk of AAD-related hospitalization. Several susceptible groups are affected by cold temperatures and have a higher risk of hospitalization.

Can the Novel Photon-Counting CT Scan Accurately Predict Aortic Wall Thickness? Preliminary Results

BACKGROUND

Surgical indication of ascending thoracic aortic aneurysms (ATAA) is generally performed in prevention. Guidelines use aortic diameter as a predictor of rupture and dissection; however, this single parameter alone has a limited value in predicting the real-world risk of acute aortic syndromes. The novel photon-counting CT scan(pc-CT) is capable of better-analyzing tissue composition and aortic characterization. The aim of the study is to assess whether the correlation between aortic wall thickness measured with a pc-CT scan and histology exists.

METHODS

14 Patients, with a mean age of 47 years, undergoing cardiac surgery for ATAA, who had preoperatively undergone a pc-CT scan, were retrospectively analyzed. Histology analyses of the resected aortic wall aneurysm were reviewed, and minimum/maximum measurements of intima+media of the aortic wall were performed. Radiology images were also examined, and aortic wall thickness measures were taken. Bland-Altman plots and Passing-Bablock regression analyses were conducted to evaluate the correlation between the values.

RESULTS

pc-CT scan mean measurements were 1.05 and 1.69 mm, minimum/maximum, respectively. Mean minimum/maximum histology measurements were 1.66 and 2.82 mm, respectively. Bland Altman plots and Passing-Bablock regression analyses showed the absence of systematic bias and confirmed that measurement values were sufficiently similar (minimum -0.61 [CI 95% 0.16-1.38]; maximum -1.1 [0.73-2.99]).

CONCLUSIONS

Despite results being merely preliminary, our study shows encouraging sufficiently similar results between aortic wall thickness measurements made with pc-CT scan and histology analyses.

Utilizing CO2 Cone Beam Computed Tomography for Post-Procedure Completion Control Following Fenestrated Endovascular Repair of Complex Aortic Aneurysm With a Standardized CO2 Protocol

PURPOSE

To assess the feasibility and efficacy of a standardized CO2 protocol and CO2 cone beam computed tomography (CBCT) for procedural completion in fenestrated endovascular aneurysm repair (FEVAR) of complex aortic aneurysms in patients with chronic kidney disease (CKD).

MATERIALS AND METHODS

Ten patients with complex aortic aneurysms and CKD (estimated glomerular filtration rate <90 ml/min) underwent FEVAR with custom-made fenestrated devices, using CO2 as the primary contrast agent. Procedures were conducted in a hybrid operating room following a standardized CO2 protocol with optimized injection parameters and visualization techniques to maximize CO2 imaging efficacy. CO2 CBCT was performed intraoperatively to verify stent graft deployment, bridging stent positioning, target vessel patency, and the presence of potential endoleaks.

RESULTS

All 10 procedures were completed successfully without intraoperative complications or CO2-related adverse effects. Completion CO2 CBCT provided clear visualization of visceral and renal vessels, and no significant endoleaks were detected. One procedure was entirely iodine contrast-free, while minimal iodine contrast was used in others to address diagnostic uncertainties. Postoperative renal function remained stable across all patients.

CONCLUSION

CO2 CBCT is a feasible and effective alternative for completion imaging in complex FEVAR procedures for patients with CKD, potentially reducing the need for iodine contrast and the associated risk of nephropathy. A standardized CO2 protocol can enhance procedural safety. Further research with larger cohorts is needed to confirm these findings.Clinical ImpactCO2 serves as the preferred contrast medium for the endovascular treatment of patients with iodine contrast allergies or those afflicted with chronic kidney disease (CKD) to preserve further renal deterioration. Ensuring protection from potentially harmful substances is paramount during endovascular repair in such patients. Equally crucial is performing the procedure safely through a standardized protocol and confirming its accuracy upon completion. Nevertheless, the possibility of employing CO2 for cone beam computed tomography provides invaluable insights into procedural efficacy, thereby enhancing outcomes for CKD patients undergoing complex endovascular repair.

The impact of preoperative maintaining antithrombotic therapy in patients undergoing non-coronary endovascular interventions

BACKGROUND

Antithrombotic medications, including antiplatelet and anticoagulant therapies, are widely used to prevent thromboembolic events in patients with cardiovascular diseases. It is common for patients on antithrombotic medications to undergo endovascular interventions though potential complications remain unclear. This study investigated the impact of continuing antithrombotic medications before endovascular interventions on perioperative clinical outcomes, particularly intraoperative blood transfusion.

METHODS

This retrospective cohort study included patients who underwent endovascular interventions between January 2019 and December 2022. Patients were divided into four groups based on the preoperative antithrombotic medications: (1) those not receiving any antithrombotic therapy; (2) those receiving single antiplatelet therapy; (3) those receiving dual antiplatelet therapy; (4) those receiving anticoagulant therapy. Clinical outcomes, including blood transfusion, hematoma and pseudoaneurysm, were analyzed using multivariate logistics regression. Subsequently, patients were stratified based on whether they received blood transfusion. All-cause mortality, adverse cardiovascular events and infectious events were used to evaluate the impact of blood transfusion.

RESULTS

A total of 5743 patients were included, with a mean age of 67.08 ± 14.27 years, and 69.81% of them were male. Common underlying conditions included hypertension (60.48%), vascular disease (28.75%), diabetes mellitus (22.60%), congestive heart failure (6.39%), and immune disease (4.21%). Compared to patients not receiving any antithrombotic medications, those undergoing dual antiplatelet therapy or anticoagulant therapy exhibited an increased risk of requiring blood transfusion (OR: 2.05, 95%CI: 1.30-3.23; OR: 1.92, 95%CI: 1.22-3.03). Subgroup analysis indicated that the risk of blood transfusion varied depending on the type of anesthesia, number of puncture sites and renal function, with a significant interaction (P < 0.05). Patients who required blood transfusion had a significantly higher rate of one-year all-cause mortality (HR: 2.18, 95% CI: 1.10-4.32) and three-month infectious events (HR: 4.92, 95% CI: 1.72-14.06).

CONCLUSIONS

Preoperative maintaining dual antiplatelet or anticoagulant therapy increased the risk of blood transfusion in endovascular interventions. Blood transfusion was independently associated with increased risk of all-cause mortality and infectious events. These findings suggested the need for tailored perioperative management of antithrombotic therapy in patients undergoing endovascular interventions.

Predictive ability of red blood cell distribution width for negative remodeling of type B aortic dissection

OBJECTIVE

To investigate the correlation between red blood cell distribution width (RDW) and negative remodeling (NR) in type B aortic dissection (TBAD).

METHODS

This study involved the retrospective analysis of clinical data of 264 patients with nonsurgical TBAD admitted to our hospital between September 2015 and September 2022. Patients underwent regular follow-up after discharge, including periodic chest and abdominal aortic computed tomography angiography. Aortic dissection false lumen expansion was evaluated based on computed tomography angiography images taken at the final follow-up. Patients were divided into two groups based on the occurrence of NR in aortic dissection: NR and non-NR groups.

RESULTS

A total of 264 patients with an average age of 60 years (63.6% male), with a mean follow-up duration of 53.5 months and a survival rate of 87.9% (232/264 patients), were enrolled. During the follow-up period, 87 patients (33.0%) developed NR of the aortic dissection (NR group). Twenty-four patients in the NR group underwent surgery, which was significantly higher than the number of patients in the non-NR group (27.6% vs 16.9%). One patient in each group died of aortic rupture. RDW levels were significantly higher in the NR than the non-NR group (13.7 ± 1.2 vs 12.7 ± 1.0; P < .001). Spearman's correlation analysis identified a positive correlation between RDW and NR (r = 0.368; P < .001). Multivariate logistic regression analysis identified elevated RDW (odds ratio, 3.910; P < .001) as an independent risk factor for NR. The receiver operating characteristic curve indicated that a cutoff point of RDW >13.7% achieved an area under the curve for prediction of 0.770, sensitivity of 75.1%, and specificity of 93.2% (95% confidence interval, 0.722-0.818; P < .001).

CONCLUSIONS

RDW is a simple, inexpensive, and effective predictive marker of NR in TBAD. Herein, we identified that an RDW of >13.7% is a risk factor for NR in patients with nonsurgical TBAD during follow-up. This limit may provide a reliable basis for assessing the need for surgical intervention, optimizing prognosis evaluation, and making clinical decisions, ultimately improving the long-term survival and quality of life of patients.

Aortic Remodeling in Patients with Arterial Hypertension: Pathophysiological Mechanisms, Therapeutic Interventions and Preventive Strategies-A Position Paper from the Heart and Hypertension Working Group of the Italian Society of Hypertension

In patient with arterial hypertension the whole aorta is exposed to increased wall stress due to pressure overload. Different blood pressure (BP) components have been reported as main determinant of aortic remodelling. In particular increased diastolic BP has been associated with aortic dilatation across all its segments with smaller increase in aortic root and ascending aorta related to increased systolic BP and pulse pressure. Optimal BP control is crucial to prevent development of aortic aneurysm and acute aortic disease. Many studies have evaluated the role of different antihypertensive drug classes for prevention of adverse aortic remodelling including beneficial effects of ACEIs, ARBs, dihydropyridinic calcium channel blockers and Beta-blockers. The present review discusses pathophysiological mechanisms, therapeutic interventions and preventive strategies for development of aortic remodeling in patients with arterial hypertension.

Outcomes of Surgical Versus Conservative Management in Stanford Type a Aortic Dissection: A Single-Center Retrospective Study

Acute aortic dissection (AAD) is a critical cardiovascular emergency marked by the rupture of the aortic intima, resulting in blood infiltration into the media and the formation of a false lumen. AAD incidence varies by area, emphasizing the need for better diagnostics and epidemiological investigations. Bucharest University Emergency Hospital's Emergency Department conducted this retrospective cohort analysis from May 2021 to May 2023. We examined 26 Stanford Type A aortic dissection patients to establish in-hospital mortality and one-year survival rates. The primary objective was to analyze demographic, clinical, and paraclinical factors and their impact on patient outcomes. A total of 57.7% of the study group was male and had a mean age of 58.2 years, and 69.2% of patients had hypertension, indicating its importance as a risk factor. Acute chest discomfort was reported by 53.8%, neurological problems by 30.8%, and syncope or hypotension by 42.3%. CT angiography and transthoracic echocardiogram (TTE) confirmed the diagnosis and assessed dissection severity. Pericardial effusion (19.2%) and moderate to severe aortic regurgitation (26.9%) were notable. Management varied by dissection intensity and location. Emergency surgery was performed in 61.5% of patients within 24 h of diagnosis, resulting in a 12.5% in-hospital death rate. Conservatively managed patients had a 60.0% in-hospital death rate. Timely intervention is crucial, since the surgical cohort had an 87.5% one-year survival rate compared to 30% for the conservatively managed cohort. Acute renal damage (25%), protracted mechanical ventilation (31.3%), and advanced supportive care infections were postoperative sequelae. Conservative care exacerbated visceral ischemia (20%) and heart failure (10%). Advanced age and hypotension upon admission were independent mortality predictors, emphasizing the need for early risk assessment and personalized treatment. Multimodal imaging, timely surgical referral, and excellent postoperative care improve AAD outcomes, according to this study.

Understanding Thoracic Aortic Disease in Women

Multifaceted disparities exist between men and women with thoracic aortic aneurysm and dissection. Despite a higher prevalence of thoracic aortic aneurysm and dissection among men, women experience disproportionately accelerated aneurysmal expansion, greater risks of rupture or dissection, and acute aortic syndromes that occur at relatively smaller diameters. In the context of acute type A aortic dissection, they also experience more complications, increased out-of-hospital mortality, delays in presentation and diagnosis, and worse postoperative survival. These gaps are largely driven by sex differences in vascular aging and remodeling, which include arterial stiffening associated with the hormonal changes that occur during menopause. Furthermore, the increased risk of acute type A aortic dissection during pregnancy in women with thoracic aortic disease necessitates a multidisciplinary approach to peripartum counseling and surveillance. Despite significant recent improvements in early postoperative outcomes, other disparities persist, emphasizing the need for sex-specific research, patient counseling, routine monitoring, and surgical thresholds to bridge the gap in outcomes of thoracic aortic care between sexes. Elucidating the underlying mechanisms of aortic aging and its difference between men and women, as well as moving toward personalized management protocols, will give rise to improved outcomes in the treatment of thoracic aortopathy.

Follow-up of incidentally detected mild to moderate ascending aortic dilation and risk factors for rapid progression in a Swedish middle-aged population

BACKGROUND

Thoracic aortic aneurysm is a life-threatening disease due to the risk for acute aortic syndromes, and subjects with dilated ascending aortas are recommended surveillance imaging to assess the need for preventive surgery. Our objectives were to investigate the progression of dilated ascending aortas and risk factors for rapid progression in a prospectively enrolled general population-based cohort of subjects aged 50-65 years.

METHODS

From the 5058 subjects prospectively enrolled in the general population-based Swedish CArdioPulmonary bioImage Study (SCAPIS) in Linköping, we followed all 74 subjects (22% female, mean age 59±4 years) with ascending aortic dilation (≥40 mm) identified by CT angiography, thoracic CT or transthoracic echocardiography. Office and home blood pressure (BP), pulse wave velocity, coronary artery calcification and carotid plaques were assessed at baseline. Transthoracic echocardiography was used to follow ascending aortic diameters over time.

RESULTS

Three subjects underwent acute or elective aortic repair before the first follow-up examination. Among the remaining subjects, the mean progression rate of ascending aortic diameter was 0.4 mm/year (range 0-1.8 mm/year) during a mean follow-up of 6.1±1.3 years. In 10 (14%) subjects, all men, no progression was seen. In multivariable analysis, higher 7-day home systolic BP was the only factor associated with faster progression rate.

CONCLUSIONS

Progression of mild to moderate ascending aortic dilation was in general slow. Our findings emphasise the benefit of home BP measurements over office BP and underline the importance of BP control in subjects with a dilated ascending aorta.

Secondary aortic intervention may not impair survival in patients treated with TEVAR for type B aortic dissection: A Finnish national registry study

BACKGROUND AND AIMS

This study investigated patients with type B aortic dissection (TBAD) who were treated with thoracic endovascular aortic repair (TEVAR). The aim was to study whether patients who needed secondary aortic intervention (SAI) had worse survival than patients who did not require SAI after the initial TEVAR.

METHODS

Data were collected from the National Care Register for Health Care (CRHC) at the Finnish National Institute for Health and Welfare. All Patients over 15 years of age with TBAD (ICD-10; I71.01) treated with TEVAR during the years 2000-2019 were included in the study. Data were collected retrospectively. A data search of the Official Statistics of Finland Cause of Death registry was carried out to identify the date and cause of death in patients with TBAD.

RESULTS

236 patients with TBAD received TEVAR as primary operative treatment from year 2000 to 2019. SAI after initial TEVAR was performed in 45 (17%) patients during median follow-up time of 5.1 years. There was no significant difference in survival between the patients who underwent primary TEVAR alone and those who required additional SAI (p = 0.063). Age-adjusted survival did not differ between the groups either. Median follow-up time was significantly longer in the SAI group compared to patients with no SAI (5.9 vs 4.9 years, p = 0.047). The most common cause of death in both groups was an aortic-related event (47%).

CONCLUSIONS

Based on this study, SAIs may not impair the overall survival of patients previously treated with TEVAR for TBAD. Systematic follow-up after the initial TEVAR may be beneficial in identifying patients with TBAD who may require secondary operation.

Endovascular Aneurysmal Repair With the INCRAFT Stent Graft System for Abdominal Aortic Aneurysms: A Combined Korean Multi-Center and Single-Center Registry Analysis

INTRODUCTION

The INCRAFT™ Stent Graft System is a trimodular, bifurcated, ultra-low-profile endovascular device designed for endovascular aneurysm repair in patients with abdominal aortic aneurysm (AAA).

MATERIALS AND METHODS

The study population comprised a prospective multi-center cohort (n = 85) and a single-center retrospective cohort (n = 61) of Korean AAA patients treated with INCRAFT. Postprocedural follow-up involved computed tomography (CT) imaging at 1 and 12 months post-procedure to monitor aneurysm dimensions and detect any endoleak.

RESULTS

The mean age of participants was 72.0 ± 7.1 years, with the majority being male (91.8%). The average maximal aortic sac diameter was 54.7 ± 8.6 mm. Technical success was achieved in 82.9%, primarily due to the relatively high incidence of type I endoleak (17.1%) observed on immediate angiographical assessment. The rate of 30-day major vascular complication was 0.7%. For the hemostasis of bilateral femoral access arteries, 57.5% required only 2 ProGlides. At the 30-day follow-up CT, the prevalence of endoleaks was 30.4% including type I (1.4%), type II (26.1%), and undermined type (2.8%). At the 12-month follow-up, the major adverse event rate was 6.2% attributed to noncardiovascular mortality. Aneurysm-related events included 3 cases (2.1%) of re-interventions due to graft occlusion (n = 2) and type II endoleak with sac expansion (n = 1). Aneurysm shrinkage and enlargement occurred in 37.8% and 3.4% of patients, respectively. At the 12-month follow-up, type II endoleak was the most frequent type, with a prevalence of 22.7%. Type I endoleak and undetermined type were found in 0.8% and 17.8% of cases, respectively, with no instances of type III endoleak.

CONCLUSION

INCRAFT demonstrated favorable early and 12-month clinical efficacy and safety profiles for treating Korean patients with AAA.

TRIAL REGISTRATION

K-INCRAFT; www.

CLINICALTRIALS

gov Identifier: NCT03952780Clinical ImpactEndovascular aneurysmal repair (EVAR) is effective treatment option for unruptured abdominal aortic aneurysm (AAA) in patients with high perioperative risk and suitable anatomy. The INCRAFT stent graft system is an ultra-low-profile endovascular graft designed for EVAR, and its efficacy and safety have been demonstrated in multi-center European and U.S.

TRIALS

Our study found that the INCRAFT stent graft system has favorable early and 12-month clinical efficacy and safety profiles in treating AAAs within Korean population, with a 30-day major vascular complications rate of 0.7% and no cases of aneurysmal-related mortality or rupture.

Current Status of Treatment for the Acute Type A Aortic Dissection in Japan

Presenting the current status of patient outcomes with acute type A aortic dissection in Japan. The Japanese Association for Thoracic Surgery (JATS), Japanese Registry of All cardiac and Vascular Disease (JROAD), Japan Registry of Acute Aortic Dissection (JRAD), Japan Cardiovascular Surgery Database (JCVSD), National Clinical Database (NCD), The Tokyo acute aortic super network, and J-Open caRdiac aortic arCH DisEase replacement Surgical TheRApy (J-ORCHESTRA) database were used. The incidence of AAD ranged from 10 to 20 per 100,000 population. Thirty percent of patients were older than 70 years. Malperfusion syndrome or ruptured aorta was found in 10-20%. Over 90% of patients had surgery within 24-hour after diagnosis. The mortality tended to be higher in the super-acute phases from onset to surgical treatment. Acute organ malperfusion requires an accurate and prompt diagnosis to proceed with an appropriate intervention before repairing the central aorta. Antegrade cerebral perfusion was used in 70-80% and deep hypothermic circulatory arrest with/without retrograde cerebral perfusion in 20-30%. High-moderate or mild hypothermia was applied in more than 50% of patients. Replacement of the ascending aorta was performed in 70% and total arch replacement in 30%. Treatment with frozen elephant trunk as well as thoracic endovascular aortic repair (TEVAR) has increased. The aortic valve was replaced in 8-10%. Thirty-day mortality was 9.0-10%. The number of operations has increased over time. Stroke occurred in 10-12%. Although the early outcomes are acceptable, there is still room to be improved in patients with preoperative comorbidities.

Real World Sex Differences in Patients Undergoing Ascending Aortic Aneurysm Surgery-A Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data

Background: Men are known to have a higher incidence of acute cardiovascular events, while women are recognized for their increased mortality following diagnosis or intervention for these conditions. The aim of this study is to explore the sex differences in clinical profiles and outcomes of patients undergoing ascending aortic aneurysm (AscAA) surgery. Methods: A PRISMA compliant literature search and data extraction were conducted using PubMed, EMBASE, and SCOPUS. Observational cohort or retrospective registries that compared a defined number of male and female adults undergoing ascending aortic surgery for AscAA were included. Data analysis was conducted in compliance with Cochrane methods. Results: A total of 11 unique studies met the inclusion criteria, from which 13636 patients were included, with a distribution of 9124 males (67%) and 4512 females (33%). Overall, 91% underwent elective surgery. Male patients had significantly lower 30-day mortality, (RR: 0.68, 95% Cl [0.57, 0.81], p < 0.0001) and shorter stays in the intensive care unit, with a mean difference (MD) of -0.48 days ([-0.84, -0.13], p = 0.008). Males were significantly younger at the time of surgery (MD: -3.94 years, 95% CI [-5.58, -2.31], p < 0.00001). Male patients had significantly more frequent concomitant CABG (21% vs. 14.5%; p < 0.0001), while females had more frequent isolated supra-coronary ascending aortic replacement (22% vs. 36%; p = 0.004). Female patients who underwent AscAA surgery had significantly lower long-term survival (HR: 1.25, [1.05, 1.50], p = 0.013). Conclusions: Women undergo surgery for AscAA at older ages and face greater mortality. The disparities in preoperative age and timing of surgery between males and females can be explained by differences in comorbidity profiles and the need for concomitant surgery.

Assessment of the thoracic aorta after aortic root replacement and/or ascending aortic surgery using 3D relaxation-enhanced angiography without contrast and triggering

Objective

Relaxation-Enhanced Angiography without Contrast and Triggering (REACT) is a novel 3D isotropic flow-independent non-contrast-enhanced MRA (non-CE-MRA) and has shown promising results in imaging of the thoracic aorta, primarily in patients without prior aortic surgery. The purpose of this study was to evaluate the performance of REACT after surgery of the aortic root and/or ascending aorta by performing an intraindividual comparison to CE-MRA.

Material and methods

This retrospective single center study included 58 MRI studies of 34 patients [mean age at first examination 45.64 ± 11.13 years, 31 (53.44%) female] after ascending aortic surgery. MRI was performed at 1.5T using REACT (ECG- and respiratory-triggering, Compressed SENSE factor 9, acquired spatial resolution 1.69 × 1.70 × 1.70 mm3) and untriggered 3D CE-MRA. Independently, two radiologists measured maximum and minimum vessel diameters (inner-edge) and evaluated image quality and motion artifacts on 5-point scales (5 = excellent) for the following levels: mid-graft, distal anastomosis, ascending aorta, aortic arch, and descending aorta. Additionally, readers evaluated MRAs for the presence of aortic dissection (AD) and graded the quality of depiction as well as their diagnostic confidence using 5-point scales (5 = excellent).

Results

Vessel diameters were comparable between CE-MRA and REACT (total acquisition time: 05:42 ± 00:38 min) with good to excellent intersequence agreement (ICC = 0.86-0.96). At the distal anastomosis (minimum/maximum, p < .001/p = .002) and at the ascending aorta (minimum/maximum, p = .002/p = .06), CE-MRA yielded slightly larger diameters. Image quality for all levels combined was higher in REACT [median (IQR); 3.6 (3.2-3.93) vs. 3.9 (3.6-4.13), p = .002], with statistically significant differences at mid-graft [3.0 (2.5-3.63) vs. 4.0 (4.0-4.0), p < .001] and ascending aorta [3.25 (3.0-4.0) vs. 4.0 (3.5-4.0), p < .001]. Motion artifacts were more present in CE-MRA at all levels (p < .001). Using CE-MRA as the standard of reference, readers detected all 25 cases of residual AD [Stanford type A: 21 (84.0%); Stanford type B: 4 (16.0%)] in REACT with equal quality of depiction [4.0 (3.0-4.5) vs. 4.0 (3.0-4.0), p = .41] and diagnostic confidence [4.0 (3.0-4.0) vs. 4.0 (3.0-4.0), p = .81) in both sequences.

Conclusions

This study indicates the feasibility of REACT for assessment of the thoracic aorta after ascending aortic surgery and expands its clinical use for gadolinium-free MRA to these patients.

Comparative Analysis of Perivascular Adipose Tissue Attenuation on Chest Computed Tomography Angiography in Patients with Marfan Syndrome: A Case-Control Study

Background: Marfan syndrome (MFS) is a rare autosomal dominant disorder affecting connective tissues due to mutations in the fibrillin-1 gene. These genetic changes often result in severe cardiovascular conditions, including asymptomatic thoracic aortic dilation potentially leading to dissection or rupture. Perivascular adipose tissue attenuation (PVAT) observed on computed tomography may serve as a marker of localized inflammation and indicate early histopathological changes in the vascular walls of MFS patients compared to healthy individuals. Objective: This study aimed to compare PVAT values between patients with MFS and healthy controls in order to explore whether MFS patients show higher PVAT secondary to these histopathological abnormalities. Methods: This case-control study assessed PVAT on ascending aorta through computed tomography angiography (CTA) in 54 genetically confirmed MFS patients and 43 controls with low ischemic risk, excluding those with known aortic aneurysms. Results: PVAT analysis revealed significant differences between the MFS patients and healthy controls (-70.6 HU [-72.6 HU to -68.5 HU] versus -75.1 HU [-77.1 HU to -73.1 HU], p = 0.002), suggesting potential early vascular changes in the MFS group. Conclusions: The findings underscore the potential diagnostic role of PVAT in patients with genetically confirmed MFS but normal ascending aorta diameter.

Influence of Surgical Expertise on Repair of Acute Type a Aortic Dissection in a Standardized Operative Setting

Background/Objectives: The influence of surgeon expertise on patients' outcomes after repair of acute type A aortic dissection (ATAAD) is not well established. The aim of this paper is to report the results of ATAAD repair performed by expert (ES) and not expert aortic surgeons (NES) in our center. Methods: We have retrospectively divided 199 patients into two groups according to the first surgeon experience (ES = 138 patients and NES = 61 patients), all being members of the aortic team. We evaluated and compared early and long-term outcomes. Results: Although the two groups were comparable in terms of clinical presentation and intraoperative setting, ES performed more aortic arch repairs (40% vs. 26%, p = 0.06) and frozen elephant trunk procedures (15% vs. 3%, p = 0.02), albeit with similar intraoperative times (median cardiopulmonary bypass time of 203 min in ES vs. 201 min in NES, respectively, p = 0.88). The 30-day mortality was the same in the two groups (8%, p = 1), and the postoperative course was similar except for a shorter in-hospital stay in the NES group (10 vs. 17 days, p = 0.04). Conclusions: In our experience, repair of ATAAD could be achieved with similar results between ES and NES. However, NES performed less technically demanding repairs. With standardization of pre-, intra-, and post-operative management, NES can be expected to increase their technical skills and be progressively involved in more complex ATAAD repairs without adversely affecting surgical results.

Impact of non-significant right coronary ostial involvement on coronary events in type A aortic dissection surgery

OBJECTIVES

Coronary-related technical complications constantly occur during type A aortic dissection surgical repair and are potentially fatal, yet their risk factors require further investigation. The intricate morphology of coronary ostial involvement may have a substantial impact.

METHODS

From June 2019 to January 2024, consecutive type A aortic dissection patients who underwent open surgery were included. Patients were divided into the coronary involvement group (non-significant involvement: Neri A-dissected intima involving the margin of the coronary ostium; significant involvement: Neri B and Neri C) and the non-involvement group. Coronary events were defined as coronary-related technical complications necessitating bailout coronary revascularization or coronary ostial repair. Logistic regression analysis identified risk factors associated with coronary events. Overall survival was estimated using Kaplan-Meier method and Cox regression analysis.

RESULTS

Of 1168 patients, 660 patients had coronary involvement, while 508 did not. Coronary events occurred in 58 patients (4.97%), including 53 (4.54%) who required bailout coronary revascularization. Patients with coronary involvement had a higher incidence of coronary events (8.18% vs 0.79%, P < 0.001). Logistic regression analysis revealed that significant right coronary involvement was associated with coronary events (odds ratio: 20.58, 95% confidence interval: 7.37-57.50, P < 0.001). Notably, non-significant right coronary involvement, accounting for 44.61% of patients, was also associated with coronary events compared to those without involvement (odds ratio: 7.05, 95% confidence interval: 2.69-18.50, P < 0.001).

CONCLUSIONS

Coronary events occurred in 4.97% patients. Significant right coronary involvement is strongly associated with coronary events; non-significant right coronary involvement, which is relatively common in surgical patients, also poses a substantial risk for coronary events and warrants attention.

Cardiovascular screening and long-term outcomes in aircraft pilots

BACKGROUND

Pilots face significant occupational risks affecting cardiometabolic health and are subject to regulatory health screenings. Cardiometabolic risk factors, cardiac screening findings and outcomes among pilots have not been well reported.

OBJECTIVES

This study aimed to investigate cardiac evaluations of asymptomatic aircraft pilots and the association between clinical risk factors and outcomes.

METHODS

Asymptomatic aircraft pilots referred for cardiac assessment between January 1991 and May 2023 were studied. Baseline characteristics, cardiac test findings and outcomes were evaluated. Major adverse clinical event (MACE) was defined as death, myocardial infarction, stroke, major arrhythmia, heart failure event or cardiac-related hospitalisation and estimated using Kaplan-Meier methods. Significant valvular disease by echocardiography was defined as stenosis, regurgitation or prolapse of moderate severity or greater. Aortic dilation by transthoracic echocardiogram (TTE) was defined as measuring ≥40 mm in diameter.

RESULTS

212 pilots met eligibility criteria for the study. The majority were white (92.9%) and male (91%) with a mean age of 58.5±10.9 years. Mean body mass index was 27.8±4.8 with comorbid hyperlipidaemia (48%), hypertension (32%), prior cancer (27%), sleep apnoea (15%), arrhythmia (12%) and known coronary artery disease (6%). Imaging revealed significant valvular disease (2.4%) and dilated aortas (16%) based on TTEs. Functional cardiac testing performed showed mean functional aerobic capacity of 109±24.6% reaching 11.89±2.65 metabolic equivalents with <8% showing positive findings per EKG or wall motion abnormalities on exercise TTE. Six patients received coronary angiography based on clinical evaluation, with two undergoing percutaneous coronary intervention. Over a 32-year period with a median (range) follow-up of 5.15 (0.1, 31.82) years, MACE incidence was 15%.

CONCLUSIONS

Asymptomatic aircraft pilots have underlying cardiovascular risk factors but good overall functional capacity, long-term outcomes and life expectancy. Prevalence of cardiac structural findings like aortic dilatation warrants increased attention during examination of these patients.

Protective Effect on Spinal Cord Injury of Prophylactic Cerebrospinal Fluid Drainage in Extensive Aortic Arch Repair for Type A Aortic Dissection: A Retrospective Cohort Study

BACKGROUND

Cerebrospinal fluid drainage (CSFD) is commonly used to manage spinal cord injury (SCI) after aortic surgery. However, there is still limited evidence regarding its effectiveness in patients with type A aortic dissection undergoing total arch replacement plus frozen elephant trunk procedure.

METHODS

A total of 1931 patients were retrospectively enrolled between 2010 and 2023. Patients with high-risk postoperative SCI (N=445) were divided into 2 groups: with or without prophylactic CSFD to evaluate the protective effect of prophylactic CSFD. Patients with postoperative SCI (N=119) were divided into 3 groups, without CSFD, therapeutic CSFD, and prophylactic CSFD, and analyzed to compare the treatment effect of different CSFD strategies.

RESULTS

Prophylactic CSFD significantly reduced the incidence of postoperative SCI in high-risk patients (26.9% versus 17.7%, P=0.029), further supported by matching weights analysis of propensity score and conditional logistic regression. Analyses of the SCI population revealed less severe SCI symptoms in patients with prophylactic CSFD, as assessed by the American Spinal Injury Association Impairment Scale (adjusted P<0.05). Multivariable ordinal logistic regression showed that compared with those without CSFD, prophylactic CSFD (P=0.003) but not therapeutic CSFD (P=0.981) was beneficial to the in-hospital recovery of postoperative SCI. Long-term SCI outcomes did not differ among groups.

CONCLUSIONS

A prominent protective effect on SCI occurrence and recovery after the total arch replacement plus the frozen elephant trunk procedure was observed with prophylactic CSFD use in patients with type A aortic dissection. However, the effectiveness of therapeutic CSFD fell short of significance.

Protein Drug Targets for Abdominal Aortic Aneurysm and Proteomic Associations Between Modifiable Risk Factors and Abdominal Aortic Aneurysm

BACKGROUND

Abdominal aortic aneurysm (AAA) is a severe aortic disease for which no pharmacological interventions have yet been developed. This investigation focused on identifying protein-based therapeutic targets and assessing how proteins mediate the interplay between modifiable risk factors and AAA development.

METHODS

Causal inferences between plasma proteins and AAA were drawn using 2-sample Mendelian randomization, followed by comprehensive sensitivity testing, colocalization, and replication efforts. Further analyses included database interrogation, single-cell RNA data analysis, enrichment analysis, protein-protein interaction networks, and immunohistochemistry to map the tissue-specific expression of these proteins, their expression within AAA tissues, and their biological roles. Mediation Mendelian randomization was employed to evaluate the mediating effects of AAA-related proteins on the associations between AAA and 3 risk factors: hypertension, smoking, and obesity.

RESULTS

A total of 43 proteins were identified as having causal links to AAA. Colocalization analysis pinpointed 13 proteins with strong evidence of colocalization with AAA. Of these, the causal involvement of 10 proteins was substantiated by external validation data. Consistent evidence for PCSK9 (proprotein convertase subtilisin/kexin type 9), IL6R (interleukin-6R), ECM1 (extracellular matrix protein 1), and ANGPTL4 (angiopoietin-related protein 4) was further validated through tissue immunohistochemistry and blood data. Moreover, Mendelian randomization analysis identified 10 proteins as mediators of the influence of hypertension, smoking, and obesity on AAA development.

CONCLUSIONS

This analysis identifies 4 proteins (PCSK9, IL6R, ECM1, and ANGPTL4) as high-priority therapeutic targets for AAA and emphasizes the intermediary role of plasma proteins in linking hypertension, smoking, obesity, and AAA. Further investigations are needed to clarify the specific roles of these proteins in AAA pathology.

The Impact of Physical Activity on Abdominal Aortic Aneurysm: A Scoping Review

BACKGROUND

Abdominal aortic aneurysm (AAA), a condition primarily affecting older men, is often asymptomatic but becomes life-threatening if rupture occurs. While AAA risk factors such as age, gender, and smoking are well-studied, physical activity (PA) may also play a critical role in managing AAA progression, though this relationship remains understudied. This scoping review aims to synthesize current knowledge on the impact of PA on AAA, examining safety, physiological effects, and potential protective effects against AAA progression.

METHODS

A comprehensive scoping review methodology was applied, covering databases from their inception to October 2024, including MEDLINE, CINAHL, Scopus, and Web of Science. Seven studies meeting the inclusion criteria were analyzed, with intervention designs ranging from cross-sectional to longitudinal studies.

RESULTS

After full-text review of 44 articles, 38 were excluded due to focus on surgical intervention or flow models. The manual screening adding one study, resulting in 7 articles included in this review. PA appears generally safe for individuals with small AAAs, with minimal adverse events reported in most studies, though one study noted a cardiac incident during exercise. PA interventions often improved cardiovascular metrics, including ventilatory threshold and inflammatory markers, yet demonstrated mixed effects on AAA growth. Notably, the protective effect of PA against AAA progression remains inconclusive, requiring further investigation.

CONCLUSIONS

This review indicates that moderate PA is generally safe and may provide health benefits for individuals with small AAAs. However, significant knowledge gaps remain, especially regarding the optimal frequency, intensity, and duration of PA, as well as its long-term impact on aneurysm progression. All these issues require objective measurement of PA to develop targeted physical activity guidelines for this population.

Exploring Disparities in Atherosclerosis Comorbidity with Aortic Aneurysm

Aortic aneurysm (AA) and atherosclerosis (AS) of various vascular beds are asymptomatic for a long time and are relatively common pathological conditions that lead to life-threatening and disabling complications. In this review, we discuss the current understanding of the high variation in direct and inverse comorbidity of AA and AS as presented in scientific publications. Estimates of AA and AS comorbidity depend on several factors, such as the location of AA (ascending or descending thoracic aorta or abdominal aorta), familial or sporadic cases of AA, syndromic forms of AA, and/or aortic valve pathology (bicuspid aortic valve [BAV]). To identify the causes of the comorbidity of AA and AS, it is important to consider and characterise many factors in detail. These factors include clinical characteristics of the patients included in a study (age, sex) and risk factors (mainly the presence of monogenic forms and BAV, hypertension, hypercholesterolaemia, diabetes mellitus, and cigarette smoking). Additionally, it is essential to consider characteristics of the disease course and the nature of multimorbidity and to take into account pathologies not only of the cardiovascular system but also of other organ systems, with special attention to metabolic and endocrine disorders.

Comparison of short-and long-term outcomes between endovascular and open repair for descending thoracic aortic aneurysm: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate and compare the efficacy of endovascular versus open repair for the treatment of patients with descending thoracic aortic aneurysm (DTAA).

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases for relevant studies was performed. Outcome data, including postoperative mortality and morbidity, operative details, all-cause survival, freedom from aortic-related survival and freedom from aortic-related re-intervention, were independently extracted by two authors in a standardized way.

RESULTS

Twenty-nine studies comprising 49 972 patients (22 049 endovascular repair; 27 923 open repair) were included. Endovascular repair was associated with a significantly lower postoperative mortality rate [odd ratio (OR): 0.57, 95% confidence interval (CI): 0.45-0.72; I 2  = 72.58%] and morbidity. In terms of long-term survival, endovascular repair yielded better freedom from aortic-related survival [hazard ratio (HR): 0.71, 95% CI: 0.54-0.93, P = 0.012] but inferior freedom from aortic-related reintervention (HR: 2.10, 95% CI: 1.45-3.04, P < 0.001). Landmark analysis revealed that the open repair group experienced better all-cause survival beyond 16 months (HR: 1.64, 95% CI: 1.53-1.75, P < 0.001). In addition, in the subgroup of patients with intact DTAA, those who underwent open repair exhibited a higher rate of postoperative mortality (OR: 0.58, 95% CI: 0.38-0.88; I 2  = 83.34%) but had better all-cause survival beyond 7 months (HR: 1.72, 95% CI: 1.61-1.84, P < 0.001) than those who underwent endovascular repair.

CONCLUSION

Among patients treated for DTAA, endovascular repair was associated with better freedom from aortic-related survival, a lower risk for postoperative mortality and morbidity, and shorter lengths of intervention, intensive care unit stay, and hospital stay than those who underwent open repair. Open repair yielded significantly better long-term all-cause survival and freedom from aortic-related re-intervention than endovascular repair.

Whole aorta imaging shows increased risk for thoracic aortic aneurysms and dilatations in relatives of abdominal aortic aneurysm patients

OBJECTIVE

For relatives of abdominal aortic aneurysm (AAA) patients, guidelines recommend abdominal imaging aimed at early detection and management of AAA, and do not include screening for thoracic aortic aneurysms (TAA). We aimed to investigate if TAA occur in undiagnosed relatives of patients with AAA without a known genetic susceptibility for aneurysms, similar to families with identified genetic susceptibilities for aneurysms like in Marfan and Loeys-Dietz syndrome, where both AAAs and TAAs occur.

METHODS

Relatives of patients with AAA were invited for noncontrast whole aorta computed tomography (CT) screening. Systematic measurements of the CT scans were used to detect aneurysms and dilatations. Classification into familial and nonfamilial was based on reported family histories. In addition, aneurysm gene panel testing of AAA index cases was used for the classification of high vs unknown genetic risk (high genetic risk: familial aneurysm or a pathogenic/likely pathogenic (P/LP) in an aneurysm gene; unknown genetic risk: no family history or P/LP).

RESULTS

Whole aorta imaging of 301 relatives of 115 index patients with AAA with noncontrast CT scans showed a 28-fold increase in TAAs in relatives (1.7% [P < .001] vs the age-adjusted population) and a high frequency of thoracic dilatations in 18% of the relatives. Thoracic aneurysms and dilatations in relatives occurred even when index patients were unaware of familial aneurysms. AAA was increased in the relatives compared with the age-adjusted population (8%; P < .001).

CONCLUSIONS

An increased risk for thoracic aneurysms and dilatations was detected by whole aorta imaging of relatives of index patients with AAA, even when index patients were unaware of familial aneurysms. These results indicate still unknown shared genetic susceptibilities for thoracic and abdominal aneurysms. Therefore, imaging of the whole aorta of relatives of all abdominal aneurysm patients, will improve early detection of aortic aneurysms in relatives of all patients with AAA.

The Role of 4D Flow MRI-derived Wall Shear Stress in Aortic Disease: A Comprehensive Review

Aortic diseases, such as aortic dissection and aortic rupture, often lead to catastrophic complications, significantly increasing morbidity and mortality. Population-based screening for early detection in asymptomatic individuals is not feasible due to high costs and practical challenges. However, recent advancements in four dimensions (4D) Flow magnetic resonance imaging (MRI) offer a comprehensive tool for evaluating hemodynamic changes within the aortic lumen. This technology allows for the quantification and visualization of flow patterns and the calculation of advanced hemodynamic parameters, such as wall shear stress (WSS). WSS is crucial in the development, risk stratification, and surgical outcomes of aortic diseases and their complications, enabling noninvasive and quantitative screening of high-risk populations. This review explores the current status and limitations of 4D flow MRI-derived WSS imaging for aortic disease.

Impact of nondiameter aortic indices on surgical eligibility: Results from the Treatment in Thoracic Aortic Aneurysm: Surgery Versus Surveillance (TITAN: SvS) randomized controlled trial

OBJECTIVES

Traditional criterion for intervention on an asymptomatic ascending aortic aneurysm has been a maximal aortic diameter of 5.5 cm or more. The 2022 American College of Cardiology/American Heart Association aortic guidelines adopted cross-sectional aortic area/height ratio, aortic size index, and aortic height index as alternate parameters for surgical intervention. The objective of this study was to evaluate the impact of using these newer indices on patient eligibility for surgical intervention in a prospective, multicenter cohort with moderate-sized ascending aortic aneurysms between 5.0 and 5.4 cm.

METHODS

Patients enrolled from 2018 to 2023 in the randomization or registry arms of the multicenter trial, Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance, were included in the study. Clinical data were captured prospectively in an online database. Imaging data were derived from a core computed laboratory.

RESULTS

Among the 329 included patients, 20% were female. Mean age was 65.0 ± 11.6 years, and mean maximal aortic diameter was 50.8 ± 3.9 mm. In the one-third of all patients (n = 109) who met any 1 of the 3 criteria (ie, aortic size index ≥3.08 cm/m2, aortic height index ≥3.21 cm/m, or cross-sectional aortic area/height ≥ 10 cm2/m), their mean maximal aortic diameter was 52.5 ± 0.52 mm. Alternate criteria were most commonly met in women compared with men: 20% versus 2% for aortic size index (P < .001), 39% versus 5% for aortic height index (P < .001), and 39% versus 21% for cross-sectional aortic area/height (P = .002), respectively.

CONCLUSIONS

One-third of patients in Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance would meet criteria for surgical intervention based on novel parameters versus the classic definition of diameter 5.5 cm or more. Surgical thresholds for aortic size index, aortic height index, or cross-sectional aortic area/height ratio are more likely to be met in female patients compared with male patients.

Retinal oculomics and risk of incident aortic aneurysm and aortic adverse events: a population-based cohort study

BACKGROUND

The asymptomatic onset and extremely high mortality rate of aortic aneurysm (AA) highlight the urgency of early detection and timely intervention. The alteration of retinal vascular features (RVFs) can reflect the systemic vascular properties, and be widely used as the biomarker for cardiovascular disease risk prediction. Therefore, we aimed to investigate associations of RVFs with AA and its progression.

METHODS

In this prospective population-based cohort study, participants with eligible fundus images and without a history of AA at recruitment were included for analysis. A fully automated Retina-based Microvascular Health Assessment System was used to quantify multidimensional RVFs including the branching angle, caliber, complexity, density, length, and tortuosity. Univariable and multivariable Cox regressions were used to estimate the association of RVFs with the incidence of AA and aortic adverse events (AAE). Furthermore, propensity score matching was performed to mitigate the confounding effects of baseline characteristics.

RESULTS

During a median follow-up of 11.0 years, 306 incident AA (164 with abdominal AA and 108 with thoracic AA) and 48 incident AAE were documented. In the fully adjusted model, the retinal arterial branching angle (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.77 to 0.99) and the central tendency and variability of minimum venular caliber were significantly associated with the risk of incident AA (HR 1.13-1.15), while the venular minimum angular asymmetry (0.48, 0.30 to 0.77) was significantly associated with the incidence of AAE. Moreover, specific alterations of RVFs were observed in different AA subtypes (caliber in abdominal AA [HR 1.21]; caliber [HR 1.21-1.28], complexity, length, and tortuosity [HR 0.77-0.82] in thoracic AA). Similar results were obtained after propensity score-matched analysis, confirming the stability of these associations.

CONCLUSIONS

We identified a significant association of certain RVFs with incident AA and AAE, implying that noninvasive, and convenient fundus photography could be a promising tool to facilitate the early detection of AA and subsequent preventative interventions.

[New innovations in cross-sectional imaging diagnostics of the aorta]

Imaging, particularly computed tomography (CT) and magnetic resonance imaging (MRI), plays a central role in the diagnostics, treatment planning and follow-up of aortic diseases. While ultrasound is often used for the initial assessment, CT enables rapid and comprehensive imaging of the aorta. The MRI is a radiation-free and when necessary, contrast agent-free alternative and provides functional imaging methods. Positron emission tomography (PET) is particularly relevant for inflammatory vascular diseases. Cross-sectional imaging has recently undergone significant development, particularly with respect to image quality and the required doses of ionizing radiation and contrast agents, spatial resolution and newer methods, such as material decomposition and functional imaging. This article provides an overview of current developments in CT angiography (CTA) and magnetic resonance angiography (MRA) and their use in selected aortic diseases in the context of the latest guidelines.

Anesthetic Management for Proximal Aortic Repair

Surgical repair of the proximal aorta is a complex endeavor, requiring cardiopulmonary bypass (CPB) and often the use of hypothermic circulatory arrest (HCA). In addition to the normal considerations for patients undergoing cardiopulmonary bypass, additional challenges include cerebral and end-organ protection during periods of circulatory arrest. This review aims to provide an up-to-date, evidence-based review on anesthetic management for proximal aortic repair.

Direct Reinfusion of Unwashed Shed Autologous Blood During Thoracoabdominal Aortic Aneurysm Repair: A Retrospective Analysis

BACKGROUND

This study's purpose was to assess whether larger volumes of reinfused unwashed shed autologous blood (SAB) were associated with adverse events within 30 days for patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair. During TAAA repair, our institution uses a system wherein SAB is filtered, but not washed or centrifuged, and then returned to the patient via a rapid-infusion device. By reinfusing SAB, the system preserves the patient's autologous whole blood and may reduce the number of allogenic transfusions required during TAAA repair, but the end-organ effects of reinfusing unwashed SAB have not been extensively evaluated.

METHODS

Using a prospectively maintained database, we retrospectively analyzed data from 972 consecutive patients who underwent open TAAA repair at our institution from 2007 to 2021 and who received SAB. Multivariable logistic regressions were performed to assess whether SAB reinfusion volume was associated with a composite outcome of adverse events, as well as operative mortality, a composite of cardiac complications, a composite of pulmonary complications, or persistent paraplegia, stroke, or postoperative renal failure.

RESULTS

Among the cohort of 972 patients, the median volume of reinfused SAB was 4159 mL (quartile1-quartile3 [Q1-Q3]: 2524-6790 mL). Greater reinfusion volumes of unwashed SAB were not associated with greater odds of composite adverse events (odds ratio [OR], 1.02 per 1000 mL increase, 97.5% confidence interval [CI], 0.94-1.09, P = .624), nor with any individual outcome-operative mortality (OR, 1.02 per 1000 mL increase, 97.5% CI, 0.93-1.12, P = .617), a composite of cardiac complications (OR, 0.98 per 1000 mL increase, 97.5% CI, 0.93-1.04, P = .447), a composite of pulmonary complications (OR, 1.00 per 1000 mL increase, 97.5% CI, 0.94-1.06, P = .963), renal failure necessitating hemodialysis (OR, 1.01 per 1000 mL increase, 97.5% CI, 0.92-1.11, P = .821), persistent paraplegia (OR, 0.97 per 1000 mL increase, 97.5% CI, 0.84-1.13, P = .676), persistent stroke (OR, 0.85 per 1000 mL increase, 97.5% CI, 0.70-1.04, P = .070), or reoperation to control bleeding (OR, 0.99, 97.5% CI, 0.87-1.13, P = .900)-when adjusted for confounders.

CONCLUSIONS

For patients undergoing open TAAA repair, larger reinfusion volumes of unwashed SAB were not associated with greater odds of major early postoperative complications.

Enhanced Vascular Smooth Muscle Cell and Extracellular Matrix Repair Using a Metal-Organic Framework-Based Co-Delivery System for Abdominal Aortic Aneurysm Therapy

The abdominal aortic aneurysm (AAA) is a severe and complex condition characterized by the pathological dilation of the abdominal aorta. Current therapeutic strategies are limited, with surgical repair being the most effective intervention due to the lack of medications that can slow aneurysmal expansion or prevent adverse events. In this study, an innovative nanoplatform, Mn-UiO-66-NH2@HA, designed to repair vascular smooth muscle cells (VSMCs), and the extracellular matrix (ECM) is developed, thereby enhancing arterial wall integrity. This nanoplatform utilizes the classic metal-organic framework (MOF) UiO-66-NH2, doped with manganese ions (Mn2+) and coated with hyaluronate tetrasaccharide (4-mer HA). The Mn-UiO-66-NH2@HA nanoparticles demonstrates excellent drug-loading efficiency, sustained release properties, and biocompatibility. In vitro, these nanoparticles significantly increases VSMC contractility and up-regulated elastin and lysyl oxidase expressions, crucial for ECM repair, while inhibiting matrix metalloproteinases. In vivo studies on an Ang II-induced AAA mouse model reveals that Mn-UiO-66-NH2@HA effectively reduces aneurysmal expansion and improves aortic structural integrity. This study presents a promising co-delivery system leveraging MOF carriers coated with 4-mer HA and Mn2+, offering a novel therapeutic strategy for the treatment and management of AAA.

Implementation of a Comprehensive Endovascular Aortic Programme and Maintenance of Clinical Excellence during Fenestrated Branched Endovascular Aortic Repair in Two Centres

OBJECTIVE

Comprehensive endovascular aortic programmes need optimal infrastructure and multidisciplinary teams to manage complex aortic aneurysms. This study assessed the implementation of such a programme in two centres and its impact on fenestrated or branched endovascular aortic repair (FB-EVAR) outcomes.

METHODS

A retrospective review of patients treated for complex abdominal and thoraco-abdominal aortic aneurysms (TAAAs) by FB-EVAR between 2013 and 2023 was undertaken. All FB-EVAR patients were analysed, including investigational trials and high risk patients with physician modified endografts. Centre 1 (2013 - 2020) and Centre 2 (2020 - 2023) were compared. Primary endpoints were 30 day and or in hospital mortality and major adverse event (MAE) rates. Secondary endpoints were procedural metrics, spinal cord injuries, freedom from all cause death, failure to rescue, and one year mortality and re-intervention rates.

RESULTS

A total of 629 patients were included (475, 75.5% at Centre 1 and 154, 24.5% at Centre 2). The median age was 74 years (interquartile range 68, 79) and 441 (70.1%) were male. Centre 2 had a higher proportion of American Society of Anesthesiology class ≥ 3, genetically triggered aortic diseases (p = .002), chronic post-dissection aneurysms, prior aortic repairs, TAAAs (each p < .001), and symptomatic, larger aneurysms (p < .021). Technical success rates were similar between centres (97.9% vs. 98.1%; p = .91). The early mortality rate was 1.1% (7/629) with no statistically significant difference. No statistically significant differences (p > .050) in new onset permanent dialysis (0.6% vs. 2.0%), major stroke (0.6% vs. 0.6%), and permanent paraplegia (0.8% vs. 2.0%) were observed. Failure to rescue rates were 5.3% in Centre 2 and 3.5% in Centre 1 (p = .74). The one year mortality rate (91% vs. 89%; p = .71) and re-intervention rate (sub-distribution hazard ratio 1.30; p = .21) were similar between centres.

CONCLUSION

FB-EVAR was performed with low mortality and risk of disabling complication rates. No differences in mortality and MAE rates were observed after establishing a comprehensive endovascular programme, despite higher risk and more extensive cases at the new institution.

A case of rapidly progressive Salmonella aortic aneurysm with acute pericarditis manifesting as a precursor

We report a case of Salmonella cardiovascular infection presenting with acute pericarditis as a precursor to the rapid progression of aortic aneurysm. An 81-year-old man presented with persistent fever and chest pain worsened with inspiration and was admitted to a nearby hospital with a diagnosis of bacterial pericarditis. However, hoarseness emerged two days later, and the patient was transferred to our hospital because of concerns about extracardiac inflammatory foci. Computed tomography (CT) revealed a periaortic exudate and aortic arch aneurysm. After transfer, blood cultures confirmed Salmonella infection. Ampicillin (ABPC) was initiated for long-term treatment of Salmonella infection, and pericarditis was treated with ibuprofen and colchicine for approximately one month. The associated symptoms and inflammatory blood data significantly improved, but five weeks later, follow-up CT revealed enlargement of the arch aneurysm. Due to the patient's age and nutritional status, thoracic endovascular aortic repair (TEVAR) was performed along with continued ABPC. Postoperatively, the infection was well-controlled, and follow-up CT revealed a size reduction in the treated aneurysm. No recurrent Salmonella-related vascular events were observed for two years after TEVAR.

Learning objective

Acute pericarditis can present as a precursor to life-threatening vascular lesions associated with Salmonella infection and requires timely and appropriate diagnosis of the etiology behind the manifestation. Patients with aortic aneurysms caused by Salmonella often do not tolerate invasive surgical treatment when diagnosed, and the lesions progress rapidly. Therefore, endovascular treatment combined with long-term antibiotic therapy may be a practical option.

Long Term Outcomes of Endovascular Repair for Blunt Traumatic Aortic Injury: A Twenty Year Multicentre Follow Up Study

OBJECTIVE

This retrospective, multicentre, observational study analysed patients who underwent endovascular repair for blunt traumatic aortic injury (BTAI) at four tertiary trauma referral centres over twenty years. It aimed to determine early and long term survival, to analyse aortic and device related complications, and to assess the re-intervention rate after endovascular repair for BTAI.

METHODS

All patients treated from 1 January 2001 to 31 October 2021 were identified using local hospital registries and two national registries: the Swedish vascular registry (Swedvasc) and Swedish trauma registry (SweTrau). Patient, treatment, and follow up data were extracted from medical records and radiology data by review of congregated imaging. The report was structured according to the STROBE checklist.

RESULTS

Ninety five patients were included: 80 were male (84%), the median age was 42 years (interquartile range [IQR] 27, 64), and median follow up time was 6.1 years (IQR 0.7, 12.4). The thirty day mortality rate was 16% (15 of 93), 40% of these were caused by traumatic brain injury and 33% by aortic related causes. Estimated overall survival was 57% (standard error 6.6) at fifteen years after index treatment. Aortic re-intervention procedures (re-stenting, coiling, or explantation) were performed in 14 of 86 patients (16%), six of whom underwent stent graft explantation. Seven of the 14 patients (50%) who underwent aortic re-intervention presented with symptoms and six of 14 had a device related complication. All complications that required aortic re-intervention were diagnosed within eighteen months of the index procedure. There was no association between injury grade and aortic re-intervention.

CONCLUSION

Thoracic endovascular aortic repair is an effective treatment for patients with BTAI needing intervention. It carries low rates of device related complications and death, and the long term outcomes are acceptable. As all aortic complications requiring re-intervention were identified during the first two years after index treatment, with half of the patients reporting symptoms, future follow up protocols should be adjusted accordingly.