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

Utilization of percutaneous closure devices for large bore arterial access in patients with genetic aortopathy does not result in increased rates of access site complications

OBJECTIVE

Percutaneous closure devices for arterial sheaths of sufficient caliber to deliver aortic endografts have a published success rate of 90% to 95%. Despite this, they are frequently avoided in patients with genetic aortopathy due to concern for high failure rates and increased complications in the setting of compromised tissue integrity. This study aims to compare rates of access site complications after large bore percutaneous access among patients with and without confirmed genetic aortopathy.

METHODS

All patients undergoing endovascular aortic procedures requiring large bore (≥9F) femoral sheath access between 2019 and 2023 were identified. The specific mutation, demographics, comorbidities, and operative details including maximum sheath size were recorded. Outcomes including unplanned femoral cutdown, access site complications, and reinterventions were evaluated. These factors were then compared between patients with and without a laboratory-confirmed mutation associated with genetic aortopathy. A supplemental analysis was then performed on all patients with genetic aortopathy from 2014 to 2023.

RESULTS

Among the 404 patients identified, 33 (8%) had confirmed genetic aortopathy. Among these, 7 patients (21%) had Marfan syndrome, 7 (21%) had Loeys-Dietz syndrome, and 3 (9%) had vascular Ehlers-Danlos. Also represented were ACTA2, PRKG1, FOXE3, and LOX mutations. The genetic aortopathy group was significantly younger (median genetic aortopathy: median 52 years; nongenetic aortopathy: 71 years; P < .001). Thoracic endovascular aortic repair was most frequent in the genetic aortopathy group (52%), followed by zone II arch replacement with frozen elephant trunk (21%); the most frequent operation among the nongenetic aortopathy group was fenestrated/branched endovascular aortic repair (43%), followed by thoracic endovascular aortic repair (25%). Both groups had a median sheath size of 20F; the patients with genetic aortopathy had higher rates of both prior open (genetic aortopathy: 27%; nongenetic aortopathy: 12%; P = .015) and prior percutaneous ipsilateral access (genetic aortopathy: 58%; nongenetic aortopathy: 39%; P = .041). Rates of unplanned cutdowns (genetic aortopathy: 0%; nongenetic aortopathy: 6%) and access site complications (genetic aortopathy: 0%; nongenetic aortopathy: 8%) did not significantly differ between groups (P = .160 and P = .096, respectively). In supplementary analysis, there was one patient with genetic aortopathy who required unplanned cutdown, yielding an overall technical success rate of 97% for percutaneous closure over a 10-year period.

CONCLUSIONS

Percutaneous access is safe and effective in patients with confirmed genetic aortopathy with similar rates of unplanned cutdown as those in patients without genetic aortopathy. Given the high rates of staged, repeat aortic procedures in this patient population, percutaneous closure should be attempted to avoid an obligate femoral incision, thereby reducing the potential for wound complications and increasing the ease of future procedures.

Impact of Open Surgical Descending Repair on Aortic Stiffness in an Ex Vivo Porcine Model

BACKGROUND

Previous studies have strongly suggested that stent-graft deployment and acute arch angulation increase aortic stiffness, the impact of surgical interposition grafting remains unclear. We investigated the impact of open surgery on aortic stiffness and compared this with stent-graft induced aortic stiffening, utilising an ex vivo model.

METHODS

Porcine thoracic aortas were connected to a mock circulatory loop. Baseline characteristics, proximal and distal flow curves (for PWV calculation), and blood pressures were recorded in a type I and III arch configuration. Subsequently, 10 cm proximal descending aorta was excised and replaced with Dacron® (IGK0018-40S). After surgery, all measurements were repeated in both arch configurations.

RESULTS

Fifteen aortas were prepared and attached to the circuit. After surgery, with both arch configurations, mean aortic PWV increased (Type I: 3.46 - 3.84 m/s (+10.7%),P < 0.001); Type III: 3.61 - 3.98 m/s (+10.4%),P = 0.001), systolic pressure remained stable (Type I: 121 - 124 mm Hg, P = 0.26; Type III: 124 - 124 mm Hg,P = 0.85), diastolic pressures decreased (Type I: 73 - 65 mm Hg,P < 0.001; Type III: 75 - 66 mm Hg,P < 0.001), and consequently mean arterial pressure decreased (Type I: 89 - 85 mm Hg,P = 0.020; Type III: 92 - 85 mm Hg,P = 0.001). The stable systolic pressure and decreased diastolic pressure, after surgery, led to an increased pulse pressure (Type I: 49 - 59 mm Hg,P < 0.001; Type III: 49 - 58 mm Hg; P < 0.001) CONCLUSIONS: Surgical interposition grafting of the proximal descending aorta increases aortic PWV, increases pulse pressure, and decreases diastolic blood pressure. These findings might be important for the long-term results of patients undergoing surgical treatment of aortic diseases.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Giant cell arteritis: Role of surgery in the management of vascular complications

Apart from life-threatening and/or functional emergencies, treatment of vascular lesions in giant cell arteritis (GCA) is medical. Revascularization may be considered if the lesion remains symptomatic or progressive despite optimal medical treatment, provided that there is no disease-related inflammation, and always managed by a team of trained experts. The main risk associated with aortic involvement (aortitis) is the development of an aneurysm, most often in the thoracic aorta, after several years of progression. Indications and surgical techniques used to manage these aneurysms follow the recommendations for the general population. In peripheral artery disease, lesions are characterized by parietal thickening, stenosis and sometimes occlusion, which can lead to exertional claudication or chronic permanent ischemia. Open or endovascular surgical management of these stenotic lesions is frequently complicated by restenosis. The role of endovascular techniques in the management of inflammatory lesions is debated, but there is a preference for open surgery, particularly in the lower limbs. Cervical and cerebral arteries also present a risk of stenosis leading to stroke. Balloon dilation and/or stenting of cervical or cerebral arteries during GCA carries a high-risk of rupture and restenosis, and remains a rescue treatment limited to certain specific cases of stroke where there are concerns about patient prognosis in the absence of intervention.

Association between the non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and mortality among hypertension patients

The non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) reflects the balance between pro- and anti-atherogenic lipoproteins. This study aims to explore the relationship between NHHR and mortality among hypertension patients. Data from 17,075 hypertensive adults in the National Health and Nutrition Examination Survey (NHANES) were analyzed. Multivariate Cox regression and restricted cubic splines were used to assess the correlation between NHHR and mortality. A segmented Cox model evaluated threshold effects, and sensitivity analyses confirmed result robustness. Machine learning algorithms were used to establish a prediction model. Over a median follow-up of 84 months, 3625 deaths occurred. A U-shaped association was observed between NHHR and both all-cause and cardiovascular mortality, with threshold values at 2.32 and 2.65. Below these thresholds, NHHR was negatively associated with mortality, while values above the thresholds were positively associated. NHHR was classified as an important variable in the prediction model, with the random survival forest (rsf) algorithm showing superior performance. This study identified a U-shaped association between NHHR and mortality in hypertension patients, with threshold points at NHHR values of 2.32 and 2.65, indicating that NHHR is a potential predictor of mortality in patients with hypertension.

One-Year Functional Outcome of Patients After Surgery for Acute Stanford Type A Aortic Dissection

BACKGROUND

Our aim was to report the functional outcome of Stanford type A aortic dissection (TAAD) after 1 year as well as morbidity and mortality.

METHODS AND RESULTS

This is a retrospective analysis including 642 patients with TAAD from January 2005 to December 2021. Mean age at TAAD was 62 years (95% CI, 61-63), and 30% of the population were women. One year after surgery for TAAD, 75% of patients were living at home with New York Heart Association functional class I. No patients were observed with New York Heart Association functional class IV. Less than 2% resided in an assisted-living facility. Eighty-five percent of nonretired patients had returned to work. Two hundred twelve (33%) patients were retired after 1 year at a mean age of 73 years (95% CI, 72-74). Stroke (defined as any kind of neurological symptoms) occurred in 148 (23%) patients and was the cause of death in 33 patients. Of the remaining patients with stroke, 115 (30%) had no residual limitations 1 year after TAAD. The cross-clamp time was significantly higher in patients with stroke (98 minutes [95% CI, 94.0-101.1] in patients without stroke versus 106 minutes [95% CI, 98.5-114.1] in patients with stroke; P=0.026). Sixty-nine percent of patients with stroke lived at home, 28% lived at home with support, and 3% lived in an assisted-living facility. One year after stroke, 77% of the patients achieved a modified Rankin Scale score ≤2, whereas no patient had a modified Rankin Scale score of 5. There was no significant correlation between sex and recovery rate (P=0.48). However, experiencing a stroke significantly increased the likelihood of residing in an assisted-living facility or receiving support at home 1 year after TAAD (odds ratio, 9.46 [95% CI, 5.06-17.70]; P<0.001). Thirty-day mortality was 11.8%, and 92 patients (14%) died within the first year after TAAD. There was no significant sex difference in mortality (P=0.101).

CONCLUSIONS

One year after surgery for Stanford acute type A aortic dissection, almost 3 out of 4 patients lived unassisted at home. Stroke survivors have a favorable outcome, with the majority having mild or no residual neurological deficits at 1 year.

Remnant cholesterol and risk of aortic aneurysm and dissection: a prospective cohort Study from the UK biobank study and mendelian randomization analysis

AIM

This study aimed to examine the relationships between remnant cholesterol (RC) and the risk of aortic aneurysm and dissection (AAD).

METHODS

This prospective cohort study included 368,139 European adults from the UK Biobank. Additionally, the causal relationship between RC and AAD was investigated using Mendelian randomization (MR) analyses.

RESULTS

During a median follow-up of 13.65 years, 1,634 cases of abdominal aortic aneurysm (AAA), 698 cases of thoracic aortic aneurysm (TAA), and 184 cases of aortic dissection (AD) were identified. Elevated RC levels were associated with an increased risk of AAA compared to the reference group ([highest vs. lowest RC levels]: adjusted hazard ratio (HR) = 1.65, 95% CI: 1.36-1.99). However, no significant association was observed between high RC levels and the risk of either TAA or AD. Two-sample MR analyses supported a significant causal effect of RC on AAA risk (odds ratio (OR) = 2.08, 95% CI: 1.70-2.56). The association between RC and AAA persisted after adjusting for the effects of RC-associated genetic variants on low-density lipoprotein cholesterol (LDL-C). In contrast, MR analyses did not indicate any causal associations between RC and TAA or AD.

CONCLUSIONS

Elevated RC was linked to a greater risk of developing AAA, with MR analyses confirming a causal relationship. These findings suggest that RC may function as a new biomarker for AAA and could be integral to strategies aimed at preventing AAA.

Utilizing Integrated Bioinformatics Analysis to Explore Potential Alterations in Mitochondrial Function Within Immune Cells Associated with Thoracic Aortic Aneurysms

Thoracic aortic aneurysm (TAA) is a life-threatening peripheral vascular disease with a complex pathogenesis. Altered mitochondrial function in vascular smooth muscle cells has been implicated in TAA development. However, the link between mitochondrial functional status and immune cell behavior in TAA patients remains largely unexplored. In this study, we analyzed several bulk RNA-seq and snRNA-seq datasets of TAA from the NCBI-GEO and Genome Sequence Archive database, identifying differentially expressed mitochondrial-related genes (DE-MRGs). To assess mitochondrial function, we calculated a mitoscore to represent the overall expression level of MRGs. Our analysis revealed mitochondrial-mediated apoptosis occurring in M1 macrophages, while CD4 + T cells demonstrated the activation of quality control mechanisms, such as mitochondrial fission. Through LASSO regression and SVM-RFE, we identified key MRGs, including MUCB, ARRB2, FRG, and ALPL, which we further validated using TAA mouse models. Additionally, we found that DE-MRGs were closely linked to methionine metabolism. In conclusion, this study highlights mitochondrial dysfunction in immune cells associated with TAA, shedding light on potential mitochondrial roles in TAA pathogenesis.

Global Epidemiology of Early-Onset Aortic Aneurysm: Temporal Trends, Risk Factors, and Future Burden Projections

BACKGROUND

Aortic aneurysm has a subtle onset, high rupture mortality, rapid progression in younger individuals, and increasing annual mortality rates. Our study aimed to estimate the global burden and trends of early-onset aortic aneurysm from 1990 to 2021.

METHODS

Participants aged 15-39 years from 204 countries and regions (Global Burdern of Disease, GBD) from 1990 to 2021.The primary assessment indicators include age-standardized death rates (ASDR), age-standardized disability-adjusted life years rates (ASDALYR), annual average percent change (AAPC), attributable risk factor proportions, slope index, concentration index, and predictive model for early-onset aortic aneurysm.

RESULTS

From 1990 to 2021, the ASDR for aortic aneurysm in adolescents and young adults increased from 0.12 (95% confidence interval [CI] 0.11, 0.14) to 0.13 (0.11, 0.14) per 100,000 population, with an AAPC of 0.08% (-0.08%, 0.25%). The ASDALYR rose from 7.25 (6.52, 8.30) to 7.35 (6.51, 8.37), with an AAPC of 0.07% (-0.09%, 0.23%). Both ASDR and ASDALYR are higher in males than females, with a declining trend in females. Higher Socio-Demographic Index (SDI) countries exhibit higher ASDR and ASDALYR compared to lower SDI countries, with a continuous decline observed in high SDI nations. Smoking remains the top risk factor, with population growth being the primary driver. Models predict a global increase in aortic aneurysm deaths, predominantly among males.

CONCLUSION

The overall burden of early-onset aortic aneurysms has exhibited an increasing trend over the last three decades, especially in lower SDI countries. There is an urgent need to develop targeted prevention and control strategies across different regions and countries worldwide.

Contribution of rare chromosome 22q11.2 copy number variants to non-syndromic bicuspid aortic valve

BACKGROUND

Bicuspid aortic valve (BAV) is the most common congenital heart defect in adults, often leading to complications such as thoracic aortic aneurysms and aortic stenosis. While BAV is frequently associated with 22q11.2 deletion syndrome (22q11.2DS), the contribution of rare copy number variants (CNVs) in this region to non-syndromic BAV is less clear. This study is aimed to assess the role of rare 22q11.2 CNVs in patients with early-onset BAV (EBAV) and to determine whether these variants are linked to an increased risk of complications.

METHODS

Whole genome microarray genotyping was conducted on 272 patients with BAV with early onset valve or aortic disease (EBAV) and 272 biological relatives. CNVs were detected using three independent algorithms, focusing on the 22q11.2 region (18-24 Mb). CNV burden in the EBAV cohort was compared with unselected European ancestry controls.

RESULTS

Rare duplications and deletions within the 22q11.2 region, particularly involving genes associated with cardiac development, were identified in 7.4% of EBAV probands. These CNVs were significantly enriched compared with the general population and segregated with BAV in families. Individuals carrying rare 22q11.2 CNVs had a higher prevalence of psychiatric diagnoses and learning difficulties, although they did not exhibit the typical features of 22q11.2DS. Importantly, these CNVs were associated with early onset or complex BAV cases, underscoring their potential clinical relevance.

CONCLUSIONS

Rare 22q11.2 CNVs play a role in non-syndromic BAV, particularly in cases with early onset or complex presentations. CNV screening could be considered as part of risk stratification for patients with BAV, helping to predict complications and guide management.

TRIAL REGISTRATION NUMBER

NCT01823432.

Chronic Post-Traumatic Aortic Isthmus Pseudoaneurysm After Conservative Management of Grade II Injury: Why Is Continuous Follow-Up Mandatory?

Background: Grade I-II blunt traumatic aortic injuries (BTAIs) are typically managed conservatively, but their long-term progression is poorly understood. Chronic pseudoaneurysms may develop years after the injury, often remaining asymptomatic and being incidentally diagnosed. Methods: Two cases of post-traumatic aortic pseudoaneurysms, detected 20 and 25 years following conservatively managed BTAIs, are reported. Additionally, a comprehensive review of all post-traumatic pseudoaneurysms reported in the MedLine (PubMed.gov, U.S. National Library of Medicine, National Institute of Health) database between January 1984 and December 2024 was performed. Results: Both our patients underwent successful hybrid procedures, with no complications at the 1- and 4-year follow-ups. Our literature review identified 37 patients across 22 studies, with 32.4% presenting asymptomatically or incidentally diagnosed through routine imaging, between 1 month and 50 years after the initial trauma. In 37.8% of cases, the patients underwent open or endovascular repair. Conclusions: This case series and literature review emphasize the importance of long-term follow-up for patients with conservatively managed BTAIs, as chronic complications such as aortic pseudoaneurysms can arise decades later. Continuous surveillance is critical to ensure early detection and management.

Fluid balance and clinical outcomes in patients with aortic dissection: a retrospective case-control study based on ICU databases

OBJECTIVES

Aortic dissection (AD) is a life-threatening condition that requires intensive care and management. This paper explores the role of fluid management in the clinical care of AD patients, which has been unclear despite the substantial existing research that has been conducted on the treatment of AD.

DESIGN

A retrospective case-control study using data for AD patients from public databases.

SETTING

Two public intensive care unit (ICU) databases with hospital courses from the USA, Medical Information Mart for Intensive Care (MIMIC)-IV critical care dataset and the eICU Collaborative Research Database, with data from 2008 to 2019.

PARTICIPANTS

A total of 751 adult AD patients with detailed fluid management records from two databases were included.

INTERVENTIONS

The mean 24-hour intake and output were calculated by dividing the total amount of intake and output by the number of days in the ICU, respectively. The mean 24-hour fluid balance was generated by subtracting the output from the intake.

OUTCOME MEASURES

The relationship between the mean 24-hour fluid management and all-cause in-hospital death was assessed through univariate and multivariable regression analyses.

RESULTS

A positive correlation was found between mean 24-hour fluid intake and in-hospital mortality among AD patients (OR 1.029, 95% CI (1.018, 1.041), p<0.001), whereas a negative correlation was revealed between mean 24-hour fluid output and in-hospital mortality (OR 0.941, 95% CI (0.914, 0.968), p<0.001). A similar result was found for mean 24-hour fluid balance (OR 1.030, 95% CI (1.019, 1.042), p<0.001), and the cut-off was selected to be 5.12 dL (AUC=0.778, OR 3.066, 95% CI (1.634, 5.753), p<0.001).

CONCLUSIONS

This study stresses the importance of fluid balance in the clinical care of AD patients and provides new insights for optimising fluid management and monitoring strategies beyond the conventional focus on blood pressure and heart rate management.

Patient Selection for Surgery vs Surveillance in Moderately Dilated Ascending Aorta: Insights From Treatment in Thoracic Aortic Aneurysm: Surgery versus Surveillance (TITAN:SvS), an International Prospective Trial

BACKGROUND

Guidelines for treating ascending thoracic aortic aneurysms (ATAA) are largely based on single-center studies. To understand factors influencing patient selection for surgery vs surveillance, patient and aneurysm characteristics were compared for patients in the randomized and registry arms of a large prospective, multicenter, multinational trial.

METHODS

TITAN:SvS (Treatment in Thoracic Aortic aNeurysm: Surgery versus Surveillance) is a large prospective multicenter study of patients with ATAA between 5.0 and 5.4 cm, randomizing patients 1:1 to initial surgery vs surveillance. Nonrandomized patients are enrolled into a registry where results of operative or surveillance strategy can be monitored prospectively. Between 2018 and 2023, 615 patients were enrolled at 22 sites in the United States and Canada. Demographic and aneurysm characteristics were compared between randomized and registry arms.

RESULTS

Compared with randomized and operative registry groups, patients in the surveillance registry were older with more comorbidities. No significant differences were observed in maximal ascending aortic diameter (5.1 cm [interquartile range, 5.0-5.2 cm] vs 5.1 cm [interquartile range, 4.9-5.2 cm] P = .2) or other aneurysm characteristics. Despite similar numbers of enrolling centers in the United States (n = 11) and Canada (n = 12), Canadian patients were more likely to be randomized (58% vs 7%, P < .01) and less likely to be enrolled in the operative (9% vs 42%, P < .01) or surveillance registry (34% vs 51%).

CONCLUSIONS

Enrollment data for TITAN:SvS suggest that patient and geographic characteristics, rather than aortic size, influence decision-making regarding the initial treatment strategy for ATAAs. These findings highlight the need for caution when generalizing outcomes from operative registries, because sicker patients may be excluded.

The protective role of SGLT2 inhibitors on aortic aneurysm mediated by oxidative stress and inflammation in type 2 diabetes mellitus

BACKGROUND

Sodium-glucose transport protein 2 inhibitors (SGLT2i) have been widely used to treat patients with type 2 diabetes mellitus (T2DM) and have demonstrated protective effects against certain cardiovascular diseases. However, no clinical research has been conducted to explore the relationship between SGLT2i and the risk of aortic aneurysm (AA).

METHODS

We extracted and analyzed the data of 4964 patients with T2DM from the First Affiliated Hospital of Zhengzhou University during July 2017 to January 2023. Multivariate Cox models, interaction analysis and Kaplan-Meier curves were performed to approximate the associations of SGLT2i therapy on the risk of AA. A sensitivity analysis was performed to test the robustness of results. Mediation analyses explored the roles of inflammatory (neutrophils, lymphocytes, C-reactive protein and alkaline phosphatase) and oxidative stress (gamma glutamyl transferase, total bilirubin, and uric acid) markers in the associations between SGLT2i and AA.

RESULTS

A total of 1942 SGLT2 inhibitor (SGLT2i) users (39.12%) and 3022 non-SGLT2 inhibitor (NonSGLT2i) users were included in final analysis. After full adjustment for potential risk factors, SGLT2i patients were associated with a lower risk of aortic aneurysm (HR, 95% CI 0.91, 0.89-0.98, p = 0.001). Dapagliflozin showed the greatest difference for reduction of aortic aneurysm incidence (HR, 95% CI 0.84, 0.80-0.95, p = 0.011). Subgroup analysis indicated that use of SGLT2i lower the risk of aortic aneurysm in some subgroups of T2DM patients. The sensitivity analysis demonstrated the robustness of the results. CRP, lymphocytes, neutrophils, and uric acid were significantly associated with both SGLT2i and AA, with mediation proportions of 13.35%, 8.83%, 9.67% and 31.17%, respectively.

CONCLUSIONS

Our study suggested that patients using SGLT2i may have a lower risk of aortic aneurysm, and this effect could potentially be mediated by inflammation and oxidative stress. Further mechanistic and prospective studies are required to verify this association.

Sex-related differences in the clinical course of aortic root and ascending aortic aneurysms: the DisSEXion Study

BACKGROUND AND AIMS

To explore male-female differences in aneurysm growth and clinical outcomes in a two-centre retrospective Dutch cohort study of adult patients with ascending aortic aneurysm (AscAA).

METHODS

Adult patients in whom imaging of an AscAA (root and/or ascending: ≥40 mm) was performed between 2007 and 2022 were included. Aneurysm growth was analysed using repeated measurements at the sinuses of Valsalva (SoV) and tubular ascending aorta. Male-female differences were explored in presentation, aneurysm characteristics, treatment strategy, survival, and clinical outcomes.

RESULTS

One thousand eight hundred and fifty-eight patients were included (31.6% female). Median age at diagnosis was 65.4 years (interquartile range: 53.4-71.7) for females and 59.0 years (interquartile range: 49.3-68.0) for males (P < .001). At diagnosis, females more often had tubular ascending aortic involvement (75.5% vs. 70.2%; P = .030) while males more often had SoV involvement (42.8% vs. 21.6%; P < .001). Maximum absolute aortic diameter, at any location, at diagnosis did not differ between females (45.0 mm) and males (46.5 mm; P = .388). In females, tubular ascending growth was faster (P < .001), whereas in males, SoV growth was faster (P = .005), corrected for covariates. Unadjusted 10-year survival was 72.5% [95% confidence interval (CI) 67.8%-77.6%] for females and 78.3% (95% CI 75.3%-81.3%) for males (P = .010). Twenty-three type A dissections occurred, with an incidence rate of 8.2/1000 patient-years (95% CI 4.4-14.1) in females and 2.4/1000 patient-years (95% CI 1.2-4.5) in males [incidence rate ratio females/males: 3.4 (95% CI 1.5-8.0; P = .004)].

CONCLUSIONS

In patients having entered a diagnostic programme, involvement of aortic segments and age- and segment-related growth patterns differ between women and men with AscAA, particularly at an older age. Unravelling of these intertwined observations will provide a deeper understanding of AscAA progression and outcome in women and men and can be used as an evidence base for patient-tailored clinical guideline development.

Impact of Aspirin Therapy on Progression of Thoracic and Abdominal Aortic Aneurysms

Background and Objective

Aortic aneurysms, including abdominal (AAA) and thoracic (TAA), pose significant challenges due to their rupture risk and complex pathophysiology. While aspirin has been proposed to manage aneurysm progression, evidence remains limited. This retrospective, single-center study used AI-driven methods to examine the association between aspirin therapy and aneurysm growth.

Methods

The study, at the University of Kentucky Healthcare, utilized de-identified electronic health record data from 2010 to 2023. To evaluate platelet counts changes, Cohort 1 included patients with AAA or TAA and matched healthy controls. Cohort 2 included AAA or TAA patients who had at least two imaging studies. Extraction of aortic diameters utilized an advanced AI-based natural language processing (NLP) algorithm to identify and extract relevant text strings related to aortic dimensions. Multivariable-adjusted linear regression analyses assessed the impact of aspirin on aneurysm progression.

Results

Cohort 1 included 11,538 participants: 5,774 controls, 3,439 with AAA, and 2,325 with TAA. Platelet counts were significantly lower in patients with aortic aneurysms compared to controls, though they were not considered thrombocytopenic. Cohort 2 included 302 AAA and 141 TAA patients. Subgroup analysis revealed that aspirin use was associated with increased AAA progression in females with small aneurysms (<50 mm). Further, aspirin therapy showed no significant impact on the annualized change in aneurysm diameter for TAA or for males with AAA.

Conclusion

Our findings suggest aspirin's effectiveness varies by sex and potentially aneurysm size, underscoring the need for further research to refine antiplatelet therapy guidelines for aortic aneurysms.

Outcomes of type A aortic dissection in Australia

INTRODUCTION

Without surgical intervention, type A aortic dissection (TAAD) carries a high risk of life-threatening complications and mortality. Due to the low incidence of aortic dissection, case numbers vary significantly between institutions. This study reports outcomes for patients undergoing surgical TAAD repair in Australia between 2001 and 2021, and the impact of institution case numbers on mortality.

METHODS

Retrospective multicentre cohort study using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) data, including consecutive adult patients undergoing surgery for TAAD. Patients were divided into groups based on 30-day mortality. Secondary morbidity outcomes are reported.

RESULTS

Between 2001 and 2021, 2604 patients (median age 65; 67% male) underwent operative intervention for TAAD. Over this period, the number of aortic dissections recorded in the database annually increased (from <50 to >200 cases per year), consistent with the increasing number of contributing institutions. Thirty-day mortality rates varied by unit from 0% to 100%, with an average over the period of 18%. Despite unit case numbers ranging from 1 or 2 to over 200 cases, funnel plot analysis demonstrated no units fell outside the accepted 99.7% control level for 30-day mortality. Individual surgeons showed decreased mortality with increased caseload. Non-survivors were more likely to have prior respiratory or cerebrovascular disease, previous myocardial infarction, or severe left ventricular dysfunction. Post-operative stroke, return to theatre for bleeding, renal failure and atrial fibrillation were more common in the non-survivors (P < 0.05).

CONCLUSION

Mortality outcomes for TAAD in Australia have improved over time, stabilizing at 18% over the last 5 years. Units performing fewer operations for TAAD showed equivalent mortality outcomes to high volume units, while surgeons performing fewer procedures displayed a higher mortality.

Dimethyl fumarate is repurposed to ameliorate aortic aneurysm and dissection in mice

Aortic aneurysm and dissection pose fatal threats but no effective drug therapies are available. Previous work has been directed to reduce risk factors or target key pathological events, but none of the translational efforts succeeds. Here, we attempt to repurpose dimethyl fumarate (DMF), an FDA-approved immunomodulatory drug for multiple sclerosis, for the treatment of aortic aneurysm and dissection. In three preclinical mouse models of abdominal aortic aneurysm (porcine pancreatic elastase perfusion or CaCl2 incubation) and thoracic aortic aneurysm and dissection (β-Aminopropionitrile feeding), DMF invariably protected mice from aneurysm growth, aortic dissection, rupture and death. Histological H&E and EVG staining demonstrated aortic architecture-preserving effects of DMF. Through transcriptome profiling and the connectivity map (CMap), we showed that DMF restored SRC-FAK signaling in aortic smooth muscle cells and increased collagen I turnover in the tunica media. Our work suggests the potential of DMF being repurposed for aortic aneurysm and dissection, and highlights the importance of SRC-FAK signaling in aortic homeostasis.

The relationship between regional mechanical properties and hemodynamic indices of the aortic arch: a preliminary study

This study aimed to investigate the relationship between regional elastic modulus and corresponding hemodynamic indices of healthy aortic arch. Porcine aortic arches (n=18) were obtained from a local abattoir and divided into 24 regions along axial and circumferential directions. Regional elastic modulus was measured by indentation tests, and elastic fiber content was assessed using Elastica van Gieson (EVG) staining. Additionally, a porcine aortic model was reconstructed based on computed tomography angiography (CTA) images, and local hemodynamic indices were calculated by the two-way fluid-structure interaction (FSI) method. The elastic modulus and elastic fiber content were inclined to be lower on the outer curvature of the aortic arch, particularly showing significant differences at the distal end. A negative correlation was found between elastic modulus and time-averaged wall shear stress (TAWSS) ( r s = - 0.762 , p = 0.028 ) at the proximal end of the porcine aortic arch. There was a significant positive correlation between elastic modulus and oscillatory shear index (OSI) ( r s = 0.714 , p = 0.047 ) at the middle of the aortic arch. The regional elastic modulus of healthy porcine aortic arch is associated with local TAWSS and OSI. The hemodynamic environment could be a contributing factor influencing the distribution of the mechanical properties on the arch.

Revisiting ascending aortic resection in the elective valve-sparing root replacement: assessing the benefits and necessity of hemiarch replacement at three centres†

OBJECTIVE

The aim of this study was to determine the indication and optimal timing for performing a hemiarch procedure in patients undergoing valve-sparing root replacement (VSRR).

METHODS

We conducted a retrospective study on 986 patients undergoing VSRR at three tertiary care centres. Inclusion criteria were all patients undergoing elective VSRR. Exclusion criteria were age <18 years, Stanford type A dissection, dissection in the arch, total aortic arch replacement or previous aortic arch replacement. We performed propensity score matching in a 1:1 ratio. The primary end-point is a composite outcome that includes mortality, aortic arch reintervention, new aortic dissection during follow-up and cerebrovascular incidents within the first 30 days.

RESULTS

A total of 401 patients (41%) had a hemiarch replacement, while 585 (59%) did not. Root phenotype was present in 565 (57%). The mean follow-up time was 4.7 years (SD ± 4.6). In the matched population, there was no significant difference in the 10-year freedom from the composite outcome between the non-hemiarch and hemiarch groups (87.3% vs 85.0%, P > 0.999). Similarly, no difference was found for aortic reinterventions (P = 0.13) or survival (P = 0.5). This was also true for patients with heritable thoracic aortic disease. However, in patients with a bicuspid aortic valve, the intervention rate was significantly higher in the hemiarch group (10.8% vs 0%, P = 0.016). There was no significant difference in the 30-day incidence of cerebrovascular accidents between the groups (5% vs 2.7% in the hemiarch group, P = 0.117). Only the distal ascending diameter showed a tendency with better outcome over 45 mm for the hemiarch procedure; otherwise, we found no reliable cut-off values based on ascending length, diameter-to-height index or ascending length-to-height index.

CONCLUSIONS

Our findings conclusively demonstrate that concomitant hemiarch replacement does not increase the perioperative risk in young patients undergoing VSRR. However, concomitant replacement does not seem to protect from aortic reinterventions during medium-term follow-up.

Thoracic Endovascular Aortic Repair for Aortic Arch Penetrating Atherosclerotic Ulcer Using Castor Single-Branched Stent-Graft With Zone 2 Landing

BACKGROUND

This study evaluated the feasibility and safety of thoracic endovascular aortic repair (TEVAR) for aortic arch penetrating atherosclerotic ulcer (PAU) using Castor single-branched stent-graft with zone 2 landing.

METHODS

Between May 2020 and April 2022, a total of 25 aortic arch PAU patients were treated by TEVAR with Castor single-branched stent-graft. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and patency of left subclavian artery (LSA).

RESULTS

All patients had aortic arch PAU with intramural hematoma (IMH). The proximal landing zone for all patients was in zone 2, which was between the distal edge of the left common carotid artery and proximal edge of LSA, in all cases. Technical success was achieved in all cases. During hospitalization after the operation, 1 patient died of gastrointestinal bleeding, and 2 patients (8.0%) had ischemic stroke. At a median follow-up of 29 months (interquartile range [IQR], 24-30 months), 2 (8.0%) patients died, including 1 ischemic stroke and 1 hemorrhagic stroke. One patient (4.0%) had reintervention owing to retrograde type A aortic dissection (RTAD) 2 months after the operation, and was successfully treated with aortic root remodeling, ascending aorta and total aortic arch replacement and frozen elephant trunk procedure. No endoleak or LSA occlusion occurred. The maximal diameter of aorta at proximal (30.2±2.4 mm vs 31.2±3.0 mm; p>0.05) and distal (25.7±2.8 mm vs 24.5±2.3 mm; p>0.05) landing zone showed no significant difference before and after the operation.

CONCLUSIONS

The TEVAR for aortic arch PAU using Castor single-branched stent-graft is a safe and efficient option with zone 2 landing.

CLINICAL IMPACT

For patients with diagnosis of PAU with IMH, TEVAR with Castor single-branched stent-graft presents low mid-term mortality and morbidity rate, which should be considered as an optimal option when proximal landing zone is insufficient and revascularization of left subclavian artery (LSA) is needed. With Castor single-branched stent-graft, LSA could be revascularized easily and accurately.

A comprehensive organ protection strategy in total arch replacement: a propensity-weighted analysis

OBJECTIVES

The goal was to report the outcomes and determine the effectiveness of a comprehensive organ protection strategy in total arch replacement.

METHODS

A total of 350 patients who underwent total arch replacement were enrolled. Fifty-four patients underwent the comprehensive organ protection strategy with bilateral antegrade cerebral perfusion and the aortic balloon occlusion technique (comprehensive strategy group); 296 patients underwent the standard strategy with unilateral antegrade cerebral perfusion (standard strategy group). Inverse probability of treatment weighting was used to balance the baseline characteristics.

RESULTS

After inverse probability of treatment weighting, the comprehensive strategy group had lower incidences of 30-day mortality (0.9% vs 4.9%, P = 0.002), continuous renal replacement therapy (0.6% vs 10.3%, P < 0.001), renal failure (4.6% vs 13.7%, P < 0.001), hepatic dysfunction (11.6% vs 21.1%, P = 0.001) and shorter duration of mechanical ventilation [16 (13, 31) vs 20 (14, 48) h, P = 0.011]. Multivariable logistic analysis showed that the comprehensive strategy was an independent protective factor of 30-day mortality [odds ratio (OR): 0.242, 95% confidence interval (CI): 0.068-0.867, P = 0.029], continuous renal replacement therapy (OR: 0.045, 95% CI: 0.008-0.264, P = 0.001), renal failure (OR: 0.351, 95% CI: 0.156-0.788, P = 0.011) and mechanical ventilation >20 h (OR: 0.531, 95% CI: 0.319-0.883, P = 0.015). Kaplan-Meier analysis showed that mid-term survival was comparable.

CONCLUSIONS

The comprehensive organ protection strategy might improve early survival, reduce the use of continuous renal replacement therapy, have protective effects on the kidney and shorten mechanical ventilation time in total arch replacement. This strategy might be considered a viable alternative in total arch replacement.

Robot-assisted anterior resection of rectal cancer in a patient with abdominal aortic aneurysm using a monitoring laparoscope: a case report

Introduction and importance

We present the first case of robot-assisted anterior resection for rectal cancer in a patient with abdominal aortic and common iliac aneurysms using a monitoring laparoscope for enhanced safety.

Case presentation

An 86-year-old man presented with bloody stool and was diagnosed with Stage IIIB rectal cancer (T3N1aM0). Preoperative computed tomography revealed a 39-mm abdominal aortic aneurysm and 25-mm left common iliac aneurysm. Robot-assisted anterior resection with D2 lymph node dissection was performed using a 5-mm laparoscope to avoid contact between robotic forceps and aneurysm. The procedure was successful, and he was discharged from the hospital on the ninth postoperative day.

Clinical discussion

Robotic surgery, owing to the lack of tactile sensation, is generally contraindicated in cases of abdominal aortic aneurysms because of the risk of vascular injury. However, this case demonstrates that real-time monitoring with a 5-mm laparoscope can effectively prevent accidental vascular injury during robotic surgery for rectal cancer.

Conclusion

This case illustrates the appropriate modifications by which robotic surgery for rectal cancer can be safely performed in patients with abdominal aortic or common iliac artery aneurysms.

Utility of structured follow-up imaging after aortic surgery

BACKGROUND

Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging.

METHODS

All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density.

RESULTS

After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years.

CONCLUSIONS

Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period.

One-stop combined coronary-craniocervical computed tomography angiography with low-dose body coverage using artificial intelligence iterative reconstruction: a clinically feasible solution to multi-territorial atherosclerosis diagnosis

Background

Computed tomography angiography (CTA) is an effective means to detect atherosclerosis yet a whole-body scan may involve excessive dose that can only be considered in extreme cases. This study is to test the feasibility and value of adding a low-dose body CTA to the combined coronary-craniocervical CTA by using artificial intelligence iterative reconstruction (AIIR).

Methods

A total of 100 patients scheduled for one-stop combined coronary-craniocervical CTA were enrolled to receive an extended CTA covering from intracranial to iliofemoral arteries, by adding a low-dose body CTA to the coronary-craniocervical CTA. Radiation dose, contrast medium volume and the resulting image quality of the added scan, reconstructed by the AIIR, were compared to those from the retrospectively collected routine-dose aortic CTA. Diagnostic findings beyond the coronary and craniocervical arteries, which would have been missed if not for the extension, and their influence on clinical management, were assessed on the low-dose images.

Results

With rather low cost of radiation and contrast dosage (1.6 mSv, 25.4 mL), the body CTA with AIIR reconstruction yielded diagnostically sufficient image quality and significantly higher contrast-to-noise ratio (CNR) as compared to routine-dose aortic CTA at various vascular locations (all P<0.05). Additional atherosclerosis was detected by the added low-dose body CTA for a substantial proportion of patients (73/100, 73%). Incidental findings in the body were found in 26 patients with 44 detections. The corresponding clinical management of 38% patients was changed due to the atherosclerotic and non-atherosclerotic vascular findings on body arteries. Most of the atherosclerosis were calcified plaques (38/73, 52%) and rated as mild stenosis (62/73, 85%). The prevalence of body arterial atherosclerosis was remarkably higher among patients diagnosed with coronary-craniocervical atherosclerosis than those without coronary-craniocervical atherosclerosis (85% vs. 22%).

Conclusions

Extending the one-stop combined coronary-craniocervical CTA with low-dose body coverage as enabled by the AIIR is technically feasible and of evident clinical value in clinical decision-making, taking a concrete step towards multi-territorial atherosclerosis diagnosis and management in practical application.

Long-term outcomes after aortic root replacement for bicuspid aortic valve-associated aneurysm

OBJECTIVE

Patients with congenital bicuspid aortic valve often require root replacement. This study aims to describe their long-term rates of mortality and reoperation.

METHODS

This is a multicenter retrospective study of 747 patients with bicuspid aortic valve who underwent aortic root replacement for aortic aneurysm between 2004 and 2020. Cumulative incidence curves for aortic valve and aortic reoperations were graphed. A Kaplan-Meier survival curve for the patient cohort was created alongside an age- and sex-matched curve for the US population. Multivariable Cox regression was used to determine characteristics associated with long-term mortality.

RESULTS

The median age of our cohort was 54 [43-64] years old, and 101 (13.5%) patients were female. In patients with bicuspid aortic valve dysfunction, 274 (36.7%) had aortic insufficiency, 187 (25.0%) had aortic stenosis, and 142 (19.0%) had both. In-hospital mortality occurred in 10 (1.3%) patients. There were 56 aortic valve reoperations and 19 aortic reoperations, with a combined cumulative incidence of 35% (95% confidence interval [CI], 23%-46%) at 15 years. In addition, there was comparable survival between the patient cohort and the age- and sex-matched US population. Age (hazard ratio [HR], 1.04; 95% CI, 1.01-1.06), concomitant CABG (HR, 2.28; 95% CI, 1.29-4.04), and bypass time (HR, 1.01; 95% CI, 1.00-1.01) were associated with increased mortality.

CONCLUSIONS

Patients who undergo aortic root replacement with bicuspid aortic valve have an increased rate of aortic reoperation (35%; 95% CI, 23%-46%) while their survival appears to be comparable to the general US population (79%; 95% CI, 73%-87%) at 15 years.

Predicting Late Adverse Events in Uncomplicated Stanford Type B Aortic Dissection: Results From the ROADMAP Validation Study

BACKGROUND

Risk stratification is highly desirable in patients with uncomplicated Stanford type B aortic dissection but inadequately supported by evidence. We sought to validate externally a published prediction model for late adverse events (LAEs), consisting of 1 clinical (connective tissue disease) and 4 imaging variables: maximum aortic diameter, false lumen circumferential angle, false lumen outflow, and number of identifiable intercostal arteries.

METHODS

We assembled a retrospective multicenter cohort (ROADMAP [Registry of Aortic Diseases to Model Adverse Events and Progression]) of 401 patients with uncomplicated Stanford type B aortic dissection presenting to 1 of 8 aortic centers between 2001 and 2013, followed until 2020. LAEs were defined as fatal or nonfatal aortic rupture, new refractory hypertension or pain, organ or limb ischemia, aortic aneurysm formation (≥6 cm), or rapid growth (≥1 cm per year). We applied the original model parameters to the validation cohort and examined the effect on risk categorization using LAE end points.

RESULTS

One hundred and seventy-six patients (44%) with incomplete imaging or clinical data were excluded. Of 225 patients in the final cohort, 90 (40%) developed LAEs, predominantly driven by aneurysm formation. Baseline maximum aortic diameter was significantly larger in patients with (42.6 [95% CI, 39.1-45.8] mm) compared with patients without LAEs (39.9 [95% CI, 36.3-44.2] mm; P=0.001). A multivariable Cox regression model indicated that only maximum diameter was associated with LAEs (hazard ratio, 1.07 [95% CI, 1.03-1.11] per mm; P<0.001), while the other parameters were not (P>0.05). Applying the original prediction model to the validation cohort resulted in a poor 5-year sensitivity (38%) and specificity (69%).

CONCLUSIONS

A clinical and imaging-based prediction model performed poorly in the ROADMAP cohort. Maximum aortic diameter remains the strongest predictor of LAEs in uncomplicated Stanford type B aortic dissection.

Microinjection of angiotensin II into zebrafish embryos induces transient dilation and elastin disruption of the dorsal aorta

The effects of angiotensin II (AngII) on blood vessel development and remodeling have been extensively investigated in mice and humans. However, its action on the vessels in the zebrafish remains largely unknown. To investigate whether AngII affects vascular morphology in vivo, we administered AngII into the endothelial-specific transgenic reporter zebrafish (Tg[kdrl:EGFP]) at the 1-cell stage. The average dorsal aortic diameter of five serial positions was significantly increased by 20% in AngII-injected zebrafish compared with buffer-injected controls at 5 days post-fertilization. Histological studies in AngII-injected zebrafish at 8 weeks post-fertilization showed that elastic fiber formation was partly attenuated, with enhanced matrix metalloproteinase-2 expression in the dorsal aorta without dilation. These results suggest that AngII induced transient aortic expansion in early larvae and may affect vascular elastic fiber formation in adult zebrafish. The use of the AngII-injected zebrafish model is a potential tool to dissect the mechanisms of disruption of elastic vascular wall formation in the aorta.

Lifetime Management for Aortic Stenosis: Strategy and Decision-Making in the Current Era

Aortic stenosis, the most common valvular disease in the Western world, has traditionally been treated with surgical aortic valve replacement (SAVR) but is increasingly treated by transcatheter aortic valve replacement (TAVR). Whereas patients older than 65 years are preferably treated with bioprosthetic tissue valves, there is considerable uncertainty in the choice between TAVR and SAVR. We present various considerations for optimizing the lifelong management of patients receiving bioprosthetic valves (SAVR or TAVR). To maximize life expectancy and to minimize cumulative lifetime risk, we suggest decision-making individualized for patient anatomy and overall (current and future) risk.

[What is new in the management of peripheral arterial occlusive disease and diseases of the aorta? : Highlights of the ESC guidelines 2024]

The European Society of Cardiology (ESC) guidelines on peripheral arterial disease (PAD) and diseases of the aorta published in September 2024 for the first time combine recommendations for both diseases in a joint guideline document. The consolidation of PAD and aorta guidelines follows a holistic approach, which underlines the entirety of the arterial vascular system. This aim is underlined by a specifically introduced recommendation to take the entirety of the circulatory system into account in patients with vascular diseases. The focus in the current ESC guideline document is on a multidisciplinary, patient-centered management of PAD and diseases of the aorta, whereby the prevention and follow-up of patients after therapeutic interventions are emphasized. In PAD the document highlights exercise training and the procedure for patients with chronic wounds as well as risk stratification and hereditary diseases of the aorta.

A multiphasic model for determination of mouse ascending thoracic aorta mass transport properties with and without aneurysm

Thoracic aortic aneurysms (TAAs) are associated with aortic wall remodeling that affects transmural transport or the movement of fluid and solute across the wall. In previous work, we used a Fbln4E57K/E57K (MU) mouse model to investigate transmural transport changes as a function of aneurysm severity. We compared wild-type (WT), MU with no aneurysm (MU-NA), MU with aneurysm (MU-A), and MU with an additional genetic mutation that led to increased aneurysm penetrance (MU-XA). We found that all aneurysmal aortas (MU-A and MU-XA) had lower fluid flux compared to WT. Non-aneurysmal aortas (MU-NA) had higher 4 kDa FITC-dextran solute flux than WT, but aneurysmal MU-A and MU-XA aortas had solute fluxes similar to WT. Our experimental results could not isolate competing factors, such as changes in aortic geometry and solid material properties among these mouse models, to determine how intrinsic transport properties change with aneurysm severity. The objective of this study is to use biphasic and multiphasic models to identify changes in transport material properties. Our biphasic model indicates that hydraulic permeability is significantly decreased in the severe aneurysm model (MU-XA) compared to non-aneurysmal aortas (MU-NA). Our multiphasic model shows that effective solute diffusivity is increased in MU-NA aortas compared to all others. Our findings reveal changes in intrinsic transport properties that depend on aneurysm severity and are important for understanding the movement of fluids and solutes that may play a role in the diagnosis, progression, or treatment of TAA.

Short segment linear "flaps" of the abdominal aorta: proposed mechanism of origin and evaluation of natural history via retrospective imaging review

PURPOSE

Luminal linear findings (LLF) of the abdominal aorta are often called aortic "flaps," triggering concern for acute aortic syndrome. However, these "flaps" are unlikely to represent intimomedial dissection given isolation to the abdominal aorta, short length, and incidental discovery. We aim to characterize the etiology and stability of LLF.

METHODS

CT reports finalized January 2021-December 2022 were queried for terms "focal dissection," "dissection flap," "linear filling defect," and "linear flap." Patients were excluded for thoracoabdominal dissection, LLF in non-aortic vessel, no prior contrast-enhanced imaging, and less than 6 months between exams. Index exam reviewed for presence of LLF, atherosclerosis, and aortic caliber at LLF site. Prior exam assessed for aortic caliber and aortic findings at subsequent LLF site. Patients with unchanged LLF between exams were categorized "Stable" and patients with interval change "Dynamic."

RESULTS

Seven hundred and two cases identified. After exclusions, imaging from 70 patients reviewed; 1 excluded for no LLF. Stable Cohort of 39 patients had median follow-up 31 months (range 6-284 months). 87% of aortas were moderately/severely atherosclerotic (n = 16 moderate, n = 18 severe), while 69% were ectatic/aneurysmal (n = 27). Dynamic Cohort of 20 patients had median follow-up of 70 months (range 14-244 months). All were atherosclerotic and 80% were ectatic/aneurysmal compared to 25% ectatic/aneurysmal at prior imaging. Mural thrombus was present at the site of the future LLF in 17 of 20, thrombosed PAU in 1, and no focal findings in 2.

CONCLUSION

Short-segment LLFs within the abdominal aorta arise from prior mural thrombus and demonstrate long term stability. Clinically and radiographically indolent, LLFs should not be called dissection flaps.

LPS-LBP complex induced endothelial cell pyroptosis in aortic dissection is associated with gut dysbiosis

Acute aortic dissection (AAD) is the most severe traumatic disease affecting the aorta. Pyroptosis-mediated vascular wall inflammation is a crucial trigger for AAD, and the exact mechanism requires further investigation. In this study, our proteomic analysis showed that Lipopolysaccharide (LPS)-binding protein (LBP) was significantly upregulated in the plasma and aortic tissue of patients with AAD. Further, 16S rRNA sequencing of stool samples suggested that patients with AAD exhibit gut dysbiosis, which may lead to an impaired intestinal barrier and LPS leakage. By comparing with control mice, we found that LBP, including Pyrin Domain Containing Protein3 (NLRP3), the CARD-containing adapter apoptosis-associated speck-like protein (ASC), and Cleaved caspase-1, were upregulated in the AAD aorta, whereas gut intestinal barrier-related proteins were downregulated. Moreover, treated with LBPK95A (an LBP inhibitor) attenuated the incidence of AAD, the expression levels of pyroptosis-related factors, and the extent of vascular pathological changes compared to those in AAD mice. In addition, LPS and LBP treatment of human umbilical vein endothelial cells (HUVECs) activated TLR4 signaling and intracellular reactive oxygen species (ROS) production, which stimulated NLRP3 inflammasome formation and mediated pyroptosis in endothelial cells. Our findings showed that gut dysbiosis mediates pyroptosis by the LPS-LBP complex, thus providing new insights into developing AAD.

Fenestrated and Branched Endovascular Aortic Repair and Mortality at Hospitals Without Investigational Device Trials

Importance

Fenestrated and branched endovascular aortic repairs (F/BEVAR) have been adopted by many centers. However, national trends of F/BEVAR use remain unclear, particularly at sites who perform them without an US Food and Drug Adminstration (FDA)-approved investigational device exemption (IDE).

Objective

To quantify the use of F/BEVAR in the US and to determine if mortality was different at IDE vs non-IDE sites.

Design, Setting, and Participants

This retrospective cohort study examined 100% fee-for-service Medicare claims data from 2016 to 2023. Participants were patients who underwent endovascular treatment of the visceral aorta incorporating 2 or more visceral artery endoprostheses. Hospitals with vs without an IDE were identified using hospitals' Employer Identification Number as a time varying exposure.

Exposure

F/BEVAR.

Main Outcomes and Measures

Trends in the center-level F/BEVAR case volume stratified by IDE status were assessed using cumulative incidence curves. Mortality outcomes at 30 days and 3 years were compared using Kaplan-Meier methods and Cox proportional hazards models with adjustment for baseline patient characteristics.

Results

From 2016 to 2023, 8017 patients were treated with F/BEVAR at 549 hospitals. The median (IQR) age was 75.8 (71.3-80.8) years; 5795 patients (72.3%) were male and 2222 (27.7%) female. A total of 2226 F/BEVAR (27.8%) were performed at 22 hospitals with an IDE. The number of patients treated with F/BEVAR increased from 771 in 2016 to 1251 in 2023. The median (IQR) annual case volume per hospital was significantly higher at IDE sites (22.3 [11.0-30.4] vs 1.2 [1.0-2.0] cases/y; P < .001); 18 IDE sites (90.0%) and 20 non-IDE sites (3.7%) completed 9 or more cases per year. The 30-day mortality (3.0% vs 4.9%) but not 3-year mortality (26.0% vs 27.1%) was lower for patients treated at hospitals with vs without an IDE. After risk adjustment, both 30-day (odds ratio, 0.47; 95% CI, 0.32-0.69) and midterm mortality (hazard ratio, 0.81; 95% CI, 0.69-0.95) were lower for patients treated at IDE sites.

Conclusions and Relevance

The use of F/BEVAR is increasing across the United States, with the majority of cases being performed outside of IDE studies and at low-volume centers. F/BEVAR performed at non-IDE centers are associated with higher adjusted 30-day and midterm mortality. Transparent outcome reporting and identification of process measures from IDE sites may help achieve more equity in patient outcomes.

Association Between Cardiac Size, Systolic Function, and Complications in Vascular Ehlers-Danlos Syndrome

Purpose: Vascular Ehlers-Danlos syndrome (vEDS) is a rare and aggressive heritable aortic disease caused by pathogenic variants in COL3A1 gene, characterized by spontaneous arterial dissection and organ rupture. The purpose of this study is to evaluate ventricular size and function and to explore their associations with complications in vEDS. Methods: Adults with genetically confirmed vEDS who underwent clinical cardiac MRI were retrospectively compared with controls matched for age and sex. Cardiac MRI analysis included assessment of ventricular volumetry and arterial vasculature. vEDS-related complications were evaluated including dissection, aneurysm, and pneumothorax. Multivariable logistic regression was performed. Results: We studied 26 individuals with vEDS (38.6 ± 15.6 years, 50.0% female) and 26 healthy controls. Median clinical follow-up was 2.4 (1.1-3.6) years. Left and right ventricular ejection fractions were lower in vEDS compared with controls (LVEF 58 ± 6% vs 61 ± 4%, P = .03; RVEF 54 ± 5% vs 58 ± 4%, P = .03). After controlling for age, sex, and antihypertensive medication, LV end-diastolic volume indexed to body surface area (LVEDVi) predicted dissections (OR 1.1, 95% CI 1.01-1.2, P = .04) and aneurysms (OR 1.1, 95% CI 1.01-1.3, P = .03). Indexed LV end systolic volume (LVESVi) also predicted aneurysms (OR 1.2, 95% CI 1.03-1.5, P = .02). LVEF predicted the presence of any complication (OR 0.71, 95% CI 0.52-0.99, P = .04). Pneumothorax occurred exclusively in vEDS group among those with LVEF <58% (below the mean), 50.0% versus 0.0%, P = .02. Those with LVEF <58% had more frequent dissection and/or aneurysm (75.0% vs 12.5%, P = .04). Conclusion: Lower LVEF and larger cardiac size are associated with complications in vEDS.

Case studies in heritable vascular disease: Proceedings of the UTHealth Houston Multidisciplinary Aortic Conference

Heritable thoracic aortic disease is caused by dominantly inherited mutations in more than a dozen genes, including TGFB2 mutations that cause Loeys-Dietz syndrome. McGovern Medical School at UTHealth Houston convenes a regular conference that includes cardiothoracic and vascular surgeons, cardiologists, geneticists, radiologists, and pathologists to formulate multidisciplinary approaches for the management of complex heritable thoracic aortic disease cases. In this report, we highlight the unique management of individuals with distinct presentations of Loeys-Dietz syndrome owing to TGFB2 mutations.

Machine Learning Model for Predicting Risk Factors of Prolonged Length of Hospital Stay in Patients with Aortic Dissection: a Retrospective Clinical Study

The length of hospital stay (LOS) is crucial for assessing medical service quality. This study aimed to develop machine learning models for predicting risk factors of prolonged LOS in patients with aortic dissection (AD). The data of 516 AD patients were obtained from the hospital's medical system, with 111 patients in the prolonged LOS (> 30 days) group based on three quarters of the LOS in the entire cohort. Given the screened variables and prediction models, the XGBoost model demonstrated superior predictive performance in identifying prolonged LOS, due to the highest area under the receiver operating characteristic curve, sensitivity, and F1-score in both subsets. The SHapley Additive exPlanation analysis indicated that high density lipoprotein cholesterol, alanine transaminase, systolic blood pressure, percentage of lymphocyte, and operation time were the top five risk factors associated with prolonged LOS. These findings have a guiding value for the clinical management of patients with AD.

The TRPM7 chanzyme in smooth muscle cells drives abdominal aortic aneurysm in mice

Ionic signaling in smooth muscle cells (SMCs) is critical for vascular homeostasis. In this study, we untangled the role of the bifunctional TRPM7 channel kinase (chanzyme) in abdominal aortic aneurysm (AAA) pathogenesis. Comparing SMC-specific, macrophage-specific and endothelial cell-specific Trpm7 knockout, we revealed that SMC-specific Trpm7 deficiency protected mice from AAA in two distinct preclinical models of the disease. We showed that the TRPM7 channel activity increased the Ca2+ and Zn2+ influx and the Ca2+/calcineurin/CRTC2/CREB-dependent and Zn2+/MTF1-dependent Mmp2 transcription. Repurposing the clinical drug FTY720 to prevent and treat AAA resulted in improved aortic phenotypes through inhibition of TRPM7 channel activity. This study highlights the ionic mechanisms underlying AAA, identifies TRPM7 as a potential therapeutic target and suggests that blocking TRPM7 channels could be a viable strategy for treating AAA.

Time is Aorta in Uncomplicated Type B Aortic Dissection

BACKGROUND

Although cardiovascular control optimization through best medical therapy remains the gold standard of treatment for uncomplicated type B aortic dissection (uTBAD) according to international guidelines, thoracic endovascular aortic repair (TEVAR) has increasingly emerged as a viable and appealing treatment option due to its potential to induce favorable aortic remodeling and improve long-term outcomes. However, the optimal timing of TEVAR in uTBAD remains a subject of debate. This narrative review aims at evaluating safety, efficacy, and outcomes of TEVAR at different time points of the disease history.

METHODS

We conducted a comprehensive literature review across multiple electronic databases, including PubMed and Scopus, to synthesize research evidence on the timing of TEVAR in uTBAD.

RESULTS

Hyperacute-phase TEVAR (<24 hours) is associated with prohibitive periprocedural risks and is thus discouraged. Acute-phase TEVAR (1-14 days) may provide benefits in aortic remodeling but it is burdened by rather elevated rates of early complications and reinterventions. The subacute phase (14-90 days) is consistently identified as the optimal therapeutic window, balancing procedural safety and efficacy, with studies reporting superior outcomes in terms of mortality, complications, and aortic remodeling. Chronic-phase TEVAR (>90 days), although sometimes necessary in cases of disease progression, is associated with poorer outcomes, including higher rates of reintervention, complications, and limited aortic remodeling with respect to the subacute phase.

CONCLUSION

The consistent findings across the studies analyzed indicate that the subacute phase offers the best combination of reduced procedural risks and favorable long-term outcomes. However, stronger evidence is needed to refine timing strategies.

Pregnancy-related chronic type A aortic dissection highlights the importance of thorough prenatal maternal examination

BACKGROUND

Aortic dissection occurs rarely during pregnancy but carries a significantly high vital risk for both the mother and the fetus. Early diagnosis and treatment are critical for a successful outcome.

CASE PRESENTATION

A 32-year-old pregnant woman at 31 weeks of gestation began experiencing shortness of breath, chest pain, and palpitations, which were attributed to an anxiety disorder she had been previously diagnosed with. The symptoms continued to worsen following the delivery when a chest computed tomography investigation revealed signs of chronic type A aortic dissection and an 80 mm post-dissection aneurysm of the ascending aorta. Aortic repair via composite aortic root replacement surgery (Bentall procedure) and partial aortic arch replacement was performed. The patient's postoperative evolution was notable for a series of complications.

CONCLUSIONS

Our report highlights the importance of thorough maternal examination during pregnancy. The high mortality rates associated with aortic dissection occurring in pregnant women and the possibility of missed intervention due to atypical clinical presentation warrant the need for standardized international protocols aimed at the prevention and timely diagnosis of prenatal aortic disease.

Clinical implication of NT-proBNP to predict mortality in patients with acute type A aortic dissection: a retrospective cohort study

OBJECTIVES

Acute type A aortic dissection is a life-threatening cardiovascular disease commonly seen in emergency department, resulting in substantial mortality and morbidity. We aimed to investigate the prognostic value of N-terminal pro-B type natriuretic peptide (NT-proBNP) among this critically ill population.

DESIGN

The design of this study was a retrospective cohort study.

SETTING

The study population was recruited in the Emergency Department of Fuwai hospital in China from 2018 to 2020.

PARTICIPANTS

We consecutively enrolled 829 patients with acute type A aortic dissection and measurable baseline NT-proBNP.

PRIMARY OUTCOME

The primary endpoint was 1-year all-cause death.

RESULTS

Based on tertiles of NT-proBNP (pg/mL), patients were stratified into low (≤150.3, n=276), intermediate (150.3-667.6, n=277) and high (>667.6, n=276) NT-proBNP groups. Compared with patients with low NT-proBNP, the Kaplan-Meier estimates for primary 1-year mortality were higher in intermediate (32.5% vs 18.1%; HR 1.91, 95% CI 1.35 to 2.69) and high (42.0% vs 18.1%; HR 2.56, 95% CI 1.84 to 3.57) NT-proBNP groups, respectively. After multivariable regression adjusted for confounders, NT-proBNP tertiles were independent predictors for 1-year mortality (adjusted HR for intermediate group 1.52, 95% CI 1.02 to 2.27; adjusted HR for high group 2.17, 95% CI 1.41 to 3.32). Notably, the predictive performance of NT-proBNP for 1-year mortality was greater in patients receiving surgery than conservative treatment (between-cohorts difference in area under the curve 0.13, Delong's test p=0.04).

CONCLUSION

NT-proBNP provides incremental prognostic information for mortality in patients with acute type A aortic dissection who underwent surgical repairment, which could aid in risk stratification as a pragmatic and versatile biomarker in this critically ill population while having limited prognostic value for those receiving conservative treatment.

From Survival to Recovery: Understanding the Life Impact of an Acute Aortic Dissection Through Activity, Sleep, and Quality of Life

Background/Objectives: An acute aortic dissection (AAD) is a cardiovascular emergency with high mortality rates if left untreated. Survival has increased due to improvements in diagnosis and therapy. However, during their recovery, survivors frequently encounter major social, psychological, and physical challenges. This study aimed to evaluate the recovery experience of AAD survivors in The Netherlands. Insights on sleep quality, physical activity, and quality of life were collected from a unique nationwide cohort of AAD survivors recruited through the national patient support network 'Stichting Aorta Dissectie Nederland'. Methods: This study was conducted among AAD survivors who were recruited through a national association for aortic dissection known as 'Stichting Aorta Dissectie Nederland (SADN)'. The participants (n = 61) completed questionnaires assessing demographic data, physical activity, sleep quality, and health-related QoL. Results: The cohort had a mean age of 60.1 years, and 47.5% of the participants were female. The prevalence of sleep disruptions was high, as 55.7% of the people were categorized as bad sleepers (PSQI > 5). Poor sleep was associated with low physical activity and a higher BMI. The physical activity levels varied, with 47.5% reporting moderate activity levels and 44.3% reporting high activity levels. The QoL scores varied greatly among the participants, with significant impairment across all fields and reduced enthusiasm for daily activities. Poor sleepers reported significantly lower QoL (p < 0.001). Conclusions: Our study highlights significant gaps in post-AAD care, particularly addressing QoL, sleep, and physical activity. By acknowledging the multifaceted nature of recovery, healthcare providers can develop tailored interventions that empower survivors to achieve better quality of life.

Vascular Pathology in Alpha 1 Antitrypsin Deficient Chronic Obstructive Pulmonary Disease and Emphysema Patients: Case Reports

Alpha 1 Antitrypsin Deficiency (AATD) is a genetic condition that results from mutations in the SERPINA1 gene, which can lead to deficient or dysfunctional Alpha 1 Antitrypsin (AAT) protein production. AATD is linked to chronic obstructive pulmonary disease (COPD) and emphysema. In addition to pulmonary manifestations, AATD has also been associated with vascular pathology due to excessive protease activity, tissue degradation, and vessel stiffening. Early AATD diagnosis is crucial to prevent progressive lung damage and associated pathologies. Here, we present case reports of two patients with AATD from the Temple University Hospital Outpatient Clinic, who exhibited aneurysms of the aorta and splenic artery. AATD should be considered a genetic risk factor for aneurysms and vascular diseases, necessitating cardiovascular monitoring in affected individuals. This report emphasizes both the need for heightened awareness of AATD as a potential etiology of unexplained vascular aneurysms, as well as the need for screening for vascular pathology in patients with AATD-associated COPD and emphysema to facilitate early intervention and improve patient outcomes.

Pre-clinical Evaluation of a New Generation Bridging Stent for Fenestrated Endovascular Aneurysm Repair Using Realistic 3D Printed Aneurysm Models

OBJECTIVE

The aim of this study was to perform a comparative pre-clinical evaluation of a new fenestrated endovascular aneurysm repair dedicated stent using perfused 3D printed patient anatomies.

METHODS

The test setup included a pulsatile pump set to reproduce human haemodynamics, four 3D printed pararenal aneurysms connected to a bench test, and four corresponding fenestrated grafts (Zenith Fenestrated; Cook, Bloomington, IN, USA). Bridging stents were sized based on analysis of patients computed tomography scans and included either four standard covered stents (BeGraft [BG]; Bentley, Hechingen, Germany) or four similar covered stent grafts mounted on a modified balloon to allow stent implantation and flaring in one step (BeFlared [BF]; Bentley). Each anatomy and corresponding endograft was used for four sets of four bridging stent implantations. Selective angiography following each stent implantation was used to assess efficacy (patency and absence of type Ic or IIIc endoleak), procedure time was recorded, and cone beam computed tomography at the end of each set of four stent implantations enabled comparison of geometric layout between stents. Physician assessment evaluated technical performance and failure modes.

RESULTS

Sixty four stents were successfully implanted. Selective angiograms depicted three type IIIc (two in BG, one in BF) and seven type Ic (four in BG, three in BF) endoleaks, which were all corrected intra-operatively. Compared with BG, the BF had a larger mean proximal diameter inside the endograft (10.5 mm vs. 9.2 mm; p < .001) and greater opening flaring angle (46.1° vs. 33.4°; p < .001). The eight procedures performed with the BF were quicker than BG (17.0 ± 4 minutes vs. 23.9 ± 4.7 minutes; p = .004). Physician assessment did not reveal any failure mode and concluded an excellent technical performance of both devices.

CONCLUSION

The BF demonstrated similar efficacy and performance compared with the BG for bridging target vessels in an innovative test setup using 3D printed patient anatomies.

Aortic and arterial manifestations and clinical features in TGFB3-related heritable thoracic aortic disease: results from the Montalcino Aortic Consortium

BACKGROUND

Pathogenic variants in TGFB3 may lead to a syndromic genetic aortopathy. Heritable thoracic aortic disease (HTAD) and arterial events may occur in TGFB3-related disease but there are limited outcomes data on vascular events in this condition.

METHODS

Clinical data, phenotypical features and aortic outcomes in individuals with pathogenic/likely pathogenic (P/LP) TGFB3 variants enrolled in the Montalcino Aortic Consortium registry were reviewed.

RESULTS

34 individuals (56% male, median age 42 years, IQR 17-49, range 3-74 years) with P/LP TGFB3 variants were studied. Craniofacial, cutaneous and musculoskeletal features seen in Loeys-Dietz syndrome were variably present. Extra-aortic cardiovascular features included arterial tortuosity (25%), extra-aortic arterial aneurysms (6%) and mitral valve prolapse (21%).Aortic dilation (Z-Score>2) was present in 10 individuals (29%) and aortic dissection occurred in 2 (6%). Type A aortic dissection occurred in two patients (aged between 55 years and 60 years), and one of these patients experienced a type B aortic dissection 6 years later. Seven adults (median age 62 years, range 32-69 years) with aortic root dilation (41-49 mm) are being followed. No patients have undergone prophylactic aortic surgery. Twenty-five per cent of children have aortic dilation. Sixty-eight per cent of the entire cohort remains free of aortic disease. No deaths have occurred.

CONCLUSIONS

TGFB3-related HTAD is characterised by late-onset and less penetrant thoracic aortic and arterial disease compared with other transforming growth factor β HTAD. Based on our data, a larger aortic size threshold for prophylactic aortic surgery is appropriate in patients with TGFB3-related HTAD compared with HTAD due to TGFBR1 or TGFBR2 variants.

Neck vessels geometry and diameter change in patients with acute type A aortic dissection

OBJECTIVE

Branched prostheses are used to treat aortic arch with dissection. However, changes in the neck vessel geometry and diameter after dissection are not well known. We aimed to evaluate neck vessels geometry and changes in diameter with dissection.

METHODS

A total of 209 patients admitted to our hospital for acute type A aortic dissection, and we excluded patients with insufficient computed tomography image to evaluate neck vessels; as such 201 patients were included. We measured the neck vessels geometry with or without dissection, and additionally evaluated the pre- and postdissection neck vessel diameters in 16 patients for whom predissection computed tomography were available.

RESULTS

The average differences between the non-dissected and dissected vessels were 3.0 mm in proximal innominate artery (IA), 2.8 mm in distal IA, 2.5 mm in proximal left carotid artery (LCCA), 3.1 mm in distal LCCA, 2.7 mm in proximal left subclavian artery (LSA), and 1.9 mm in distal LSA. The average pre- and postdissection diameters of the neck vessels were as follows: IA: 15.1 ± 2.6 and 16.7 ± 3.2 mm (P = 0.002); LCCA: 10.7 ± 0.9 and 12.3 ± 1.2 mm (P = 0.054); and LSA: 12.4 ± 2.5 and 12.8 ± 2.1 mm (P = 0.32).

CONCLUSION

In patients with acute type A aortic dissection, dissected neck vessels diameter is significantly larger than that of the non-dissected neck vessels diameter. However, the postdissection diameter changes in the neck vessels were mostly <2 mm.

A European Delphi Consensus on the Management of Abdominal Aortic Aneurysms in Patients with Heritable Aortic Diseases

OBJECTIVE

Abdominal aortic aneurysm (AAA) in a patient with an underlying heritable aortic disease (HAD) is rare, and evidence based recommendations for its management are lacking. This study aimed to generate a consensus from multidisciplinary specialists on the diagnosis, treatment, and surveillance of AAA associated with HAD and to define topics of interest for future research.

METHODS

A Delphi consensus was designed involving European multidisciplinary specialists and reported using the ACcurate COnsensus Reporting Document (ACCORD) reporting guideline. Four rounds were carried out by email: the first two rounds to agree on the content of the questionnaire and the final two rounds to reach an agreement. Questions focused on the composition of the team, imaging, clinical suspicion, genetic testing, medical management, indications for surgical repair, surgical technique, surveillance, exercise, and quality of life. The level of agreement for each question was graded using a Likert type scale and classified into four categories: A (very strong), B (strong), C (fair), and D (no agreement).

RESULTS

A total of 35 experts from 18 different hospitals and 10 different countries participated in the study: 19 vascular surgeons, 11 cardiologists, four geneticists, and one cardiac surgeon. Of the 97 statements of the final questionnaire, 16 were graded A (16%), 23 B (24%), five C (5%), 44 D (45%) and nine (9%) were invalid. The experts highlighted the need to develop personalised therapies for each pathology, as well as international multicentre databases to collect data on the natural course of AAA patients with HAD.

CONCLUSION

This Delphi process led to consensus on several aspects of care for patients with AAA and underlying HAD, providing guidance to manage them in a more standardised fashion. The agreements reached focus on multidisciplinary aortic teams, imaging and genetic diagnosis, treatment, and follow up. Furthermore, several topics for future research were identified.

Critical Review of Guidelines for Type B Aortic Dissection

The management of type B aortic dissection is one of the most challenging and debated topics in contemporary cardiovascular surgery practice. Patients with acute or chronic dissection-related complications face high morbidity and mortality if not treated promptly. For most patients requiring intervention, thoracic endovascular aortic repair (TEVAR) is considered the gold standard. However, both early and late TEVAR-related complications make decision-making complex, even for experienced clinicians. In many cases, optimal medical management with longitudinal imaging surveillance may be preferred. In response to these challenges, several societal guidelines have recently been published to provide evidence-based or expert consensus "best practice" recommendations. Although these guidelines share many commonalities, they also highlight key unresolved clinical questions. For example, debates persist over the appropriate use of TEVAR for "uncomplicated" TBAD, defining "high-risk" criteria for uncomplicated presentations, and management of the false lumen, among other topics. Despite recent updates, a critical evaluation of the nuanced differences between these guidelines is lacking. Therefore, the purpose of this review is to compare current clinical practice guidelines, highlight their similarities and differences, and offer a comprehensive evaluation of the evidence surrounding management of TBAD. Moreover, this analysis will provide recommendations to address important knowledge gaps.