Risk factors for prophylactic proximal aortic replacement in the current era

Minimally Invasive Endovascular Repair for Nondissected Ascending Aortic Disease: A Systematic Review

Objective

The aim of this study is to evaluate the efficacy of endovascular treatment for nondissected diseases of the ascending aorta. Data Sources. PubMed, Embase, and SciELO. Review Methods. In this study, we conducted a search on the PubMed, Embase, and SciELO databases for all cases of ascending aortic endovascular repair included in the literature published between January 2007 and July 2023, excluding type A aortic dissection. We reviewed 56 case reports and 7 observational studies included in this study, assessing the techniques, equipment, procedural steps, and results. We summarized the age, complications, follow-up time, and access route.

Results

This study includes 63 articles reporting 105 patients (mean age: 64.96 ± 17.08 years) who received endovascular repair for nondissected ascending aortic disease. The types of disease include aneurysm (N = 16), pseudoaneurysm (N = 71), penetrating aortic ulcer (N = 10), intramural hematoma (N = 2), thrombosis (N = 2), iatrogenic coarctation (N = 1), and rupture of the aorta (N = 3). The success rate of surgery is 99.05% (104/105). Complications include endoleak (10.48%, 11/105), stroke (5.71%, 6/105), postoperative infection (1.91%, 2/105), acute renal failure (0.95%, 1/105), aortic rupture (0.95%, 1/105), thrombosis (0.95%, 1/105), and splenic infarction (0.95%, 1/105). Five patients required conversion to open surgery, two patients underwent endovascular reintervention, and four of these five patients underwent surgery due to endoleak. Early mortality was 2.86% (3/105).

Conclusion

While the viability and results of endovascular repair for the treatment of ascending aortic disease are acknowledged in some circumstances, further research is needed to determine the safety and effectiveness of endovascular treatment for ascending aortic disease.

The Clinical Impact of Thoracic Endovascular Aortic Repair in the Management of Thoracic Aortic Diseases

PURPOSE

Thoracic endovascular aortic repair (TEVAR) has been described to be superior to an open surgical approach, and previous studies have found superiority in TEVAR by reducing overall morbidity and mortality rates. This study aimed to describe the outcomes of TEVAR for patients with thoracic aortic disease at a high complexity.

MATERIALS AND METHODS

Descriptive study, developed by a retrospective review of a prospectively collected database. Patients aged above 18 years who underwent TEVAR between 2012 and 2022 were included. Patient demographics, perioperative data, surgical outcomes, morbidity, and mortality were described. Statistical and multivariate analyses were made. Statistical significance was reached when p values were <0.05.

RESULTS

A total of 66 patients were included. Male patients were 60.61% and the mean age was 69.24 years. Associated aortic diseases were aneurysms (68.18%), ulcer-related (4.55%), intramural-related hematoma (7.58%), trauma-related pathology (1.52%), and aortic dissection (30.30%). The mean hospital stay was 18.10 days, and intensive care unit was required for 98.48%. At 30 days, the mortality rate was 10.61% and the reintervention rate was 21.21%. Increased intraoperative blood loss (p=0.001) and male sex (p=0.04) showed statistical relationship with mortality. Underweight patients have 6.7 and 11.4 times more risk of complications and endoleak compared with higher body mass index values (p=0.04, 95% confidence interval [CI]=0.82-7.21) and (p=0.02, 95% CI=1.31-12.57), respectively.

CONCLUSION

Thoracic endovascular aortic repair seems to be a feasible option for patients with thoracic aortic pathologies, with adequate rates of mortality and morbidity. Underweight patients seem to have an increased risk of overall morbidity and increased risk for endoleak. Further prospective studies are needed to prove our results.

CLINICAL IMPACT

Obesity and BMI are widely studied in the surgical literature. According to our study, there is a paradox regarding the outcomes of patients treated with TEVAR in terms of postoperative complications and mortality related to the body mass index. And shouldn't be considered as a high-risk feature in terms of postoperative morbidity and mortality in this procedure.

Back-Table Modified Stent-Graft for Endovascular Repair of Ascending Aorta

OBJECTIVES

To investigate the effectiveness of modified stent-grafts (SGs) for the management of ascending aortic pathologies.

MATERIALS AND METHODS

From January 2015 to December 2019, 31 individuals were treated by ascending aortic endovascular repair with a back-table modified SG for acute (n=4) or chronic (n=1) type A aortic dissections, penetrating aortic ulcers (n=18), pseudoaneurysms (n=2), anastomotic fistula (n=1), and endoleaks after thoracic endovascular aortic repair (TEVAR) (n=5). The commercially available thoracic aortic SGs were modified with a fenestration or truncation technique on the back-table according to aortography during the operation.

RESULTS

The 30-day mortality and aorta-related mortality rates were 12.9% and 6.5%, respectively. There were 2 strokes, 3 respiratory insufficiencies, and 6 endoleaks during hospitalization. During a mean follow-up of 28.8±16.6 months, the overall survival rates at 1 year and 3 years were both 80.6%. Free from adverse event rates at 1 year and 3 years were 88.9% and 84.7%, respectively. There were 2 deaths during follow-up: One patient died of cachexia 1 month after discharge, and the other patient died of acute myocardial infarction 3 months after discharge. One patient with a pseudoaneurysm underwent open ascending aorta replacement 3 months after discharge for a type Ia endoleak. Another patient suffered from cerebellar infarction 17 months after discharge.

CONCLUSION

The modified SG for endovascular repair of the ascending aorta is a practicable alternative and presents acceptable outcomes in high-risk patients.

Acute Type A Dissection during Pregnancy with Marfan's Syndrome

Background  Marfan's syndrome (MFS) is a connective tissue disorder, caused by a mutation in the FBN-1 gene and affecting multiple organ systems including the vascular system. During pregnancy, women with MFS have an increased risk of aortic dissection due to changes in the cardiovascular system.

Case Description  We present a 39-year-old woman that suffered from an acute aortic dissection in week 33 of her third pregnancy who urgently required lifesaving surgery. Three-dimensional reconstruction of computed tomography scan was performed with unborn child in utero.

Conclusion  Monitoring of patients with suspected or confirmed MFS appears essential and interdisciplinary treatment and prevention strategies are required.

Preoperative renal function affects outcomes of surgery for aortic arch aneurysm in the elderly

OBJECTIVES

This study aimed to determine the optimal surgical procedure for arch aneurysm in the elderly based on preoperative comorbidities, especially focusing on renal function.

METHODS

The medical records of 374 patients who experienced arch surgery between 2008 and 2019 were reviewed. Among the 374 patients, 92 who underwent total arch replacement (TAR) were assigned to the TAR group and the remaining 152 who underwent debranching thoracic endovascular aortic repair (DTEVAR) were assigned to the DTEVAR group.

RESULTS

Chronic kidney disease (CKD) was an independent risk factor of mortality (hazard ratio, 2.85; p = 0.029) in the TAR group but not in the DTEVAR. In the Grade I/II category CKD (estimated glomerular filtration rate (eGFR) > 60 mL/min), freedom from all-cause mortality was significantly higher in the TAR group than in the DTEVAR group (p = 0.0155, log-rank). Freedom from all-cause mortality was comparable between the two groups in the Grade IIIa CKD (eGFR, 45-60) (p = 0.584, log-lank), Grade IIIb (eGFR, 30-45) (p = 0.822), and Grade IV/V (eGFR < 30) (p = 0.548).

CONCLUSION

In elderly patients who underwent TAR, CKD was the independent risk factor of the mortality, but not in the patients who underwent debranching TEVAR. Conversion of surgical strategy from TAR to debranching TEVAR in the treatment of aortic arch aneurysms in the elderly with CKD below Grade IIIa is acceptable considering that less-invasiveness. While, in the elderly with Grade I/II CKD, TAR still remains as a primary choice for the arch repair for better mid-term survival.

Endovascular treatment of non-dissected ascending aorta disease: a systematic review

Severe ascending aorta disease includes aneurysms, pseudoaneurysms (ascending aorta pseudoaneurysms), penetrating aortic ulcers and Type A aortic dissections. Surgical replacement of the aortic root, ascending aorta or aortic arch is the common treatment for severe ascending aortic disease involving the root, the ascending aorta and/or the arch. Despite good surgical results, there is still a risk for morbidity and mortality following surgery for ascending aorta replacement when elderly patients or patients at high risk for surgery are concerned. Less invasive endovascular treatments for ascending aorta repair are under evaluation, and some reports appeared in the available literature in the last decade. However, clinical series or randomized studies are not yet available, and the use of these techniques is still questionable. In this study, we analysed the outcomes of reported cases of endovascular treatment for ascending aorta disease, excluding Type A aortic dissection. We reviewed reports published until February 2017, and we evaluated the employed technology, the devices, the procedural steps and the outcomes. A total of 26 articles reported 67 patients (mean age 65 ± 17 years) who received endovascular treatment for ascending aorta disease: aneurysms, ascending aorta pseudoaneurysms, penetrating aortic ulcers, intramural haematoma, thrombosis, iatrogenic coarctation and aortic rupture. Complications included endoleak (9 cases), stroke (3 cases), non-ST-elevation myocardial infarction (1 case) and splenic infarction (1 case). Three patients required conversion to open surgery, and 1 patient underwent endovascular reintervention. Early mortality was 2.9%. As an alternative treatment for ascending aorta disease in selected high-risk patients, the endovascular repair will gain popularity, but further analysis is required.

Suitability of the porcine aortic model for transcatheter aortic root repair

OBJECTIVES

To treat aortic valve disease and concomitant root disease with transcatheter techniques, 'composite graft' implants are required. Our goal was to assess the suitability of the porcine aortic root for transcatheter root repair tests.

METHODS

Eight pig hearts explanted from domestic pigs used in experimental surgery were compared to data from the literature on human hearts. The measured diameters included those of the annulus, sinuses of Valsalva, coronary ostia, sinotubular junction, ascending aorta, innominate artery and aortic arch. The measured distances were from the coronary ostia to the nadir of the corresponding annulus; from the innominate artery to the nadir of the corresponding annulus; from the small curvature of the arch to the nadir of the corresponding annulus.

RESULTS

The mean weight of the pigs was 89 ± 5.4 kg. The mean aortic annulus diameter was 20 ± 1.2 mm (human: 23.0 ± 2.5 mm), the sinus of Valsalva diameter was 20.5 ± 0.5 mm (human: 31.4 ± 3.4 mm) and the sinotubular junction diameter was 20 ± 0.9 mm (human: 27.2 ± 3.0 mm). The diameter of the mean ascending aorta was 19 ± 0.7 mm (human: 29.3 ± 4 mm); the diameter of the innominate artery was 8.5 ± 0.7 mm, that of the aortic arch was 15 ± 0.7 mm and that of the coronary ostia was 5 ± 0.5 mm (left) and 4.7 ± 0.5 mm (right) (human: 4.8 ± 0.5 mm and 3.7 ± 0.9 mm). The distances from the left and right coronary orifices to the corresponding annuli were 8 ± 1.5 mm and 14 ± 2.4 mm, respectively (human: 14.7 ± 1.3 mm; 15.4 ± 1.7 mm). The distances from the innominate artery to the nadirs of the left and right coronary annuli were 44 ± 4.3 mm and 41 ± 4 mm (human: 80 ± 17 mm). The distance from the curvature of the small arch to the annulus was 35 ± 4.9 mm.

CONCLUSIONS

The porcine heart can be used as an experimental model to design and test new devices for catheter-based composite repair of the aortic root. Nevertheless, caution is required in using devices with tailored dimensions that must be adapted to the smaller pig's root.

Aortic events in a nationwide Marfan syndrome cohort

BACKGROUND

Marfan syndrome is associated with morbidity and mortality due to aortic dilatation and dissection. Preventive aortic root replacement has been the standard treatment in Marfan syndrome patients with aortic dilatation. In this study, we present aortic event data from a nationwide Marfan syndrome cohort.

METHOD

The nationwide cohort of Danish Marfan syndrome patients was established from the Danish National Patient Registry and the Cause of Death Register, where we retrieved information about aortic surgery and dissections. We associated aortic events with age, sex, and Marfan syndrome diagnosis prior or after the first aortic event.

RESULTS

From the total cohort of 412 patients, 150 (36.4 %) had an aortic event. Fifty percent were event free at age 49.6. Eighty patients (53.3 %) had prophylactic surgery and seventy patients (46.7 %) a dissection. The yearly event rate was 0.02 events/year/patient in the period 1994-2014. Male patients had a significant higher risk of an aortic event at a younger age with a hazard ratio of 1.75 (CI 1.26-2.42, p = 0.001) compared with women. Fifty-three patients (12.9 %) were diagnosed with MFS after their first aortic event which primarily was aortic dissection [n = 44 (83.0 %)].

CONCLUSION

More than a third of MFS patients experienced an aortic event and male patients had significantly more aortic events than females. More than half of the total number of dissections was in patients undiagnosed with MFS at the time of their event. This emphasizes that diagnosing MFS is lifesaving and improves mortality risk by reducing the risk of aorta dissection.

Dimensions of the ascending aorta in children and adolescents with repaired Tetralogy of Fallot obtained by cardiac magnetic resonance angiography

Introduction

Dilatation of the ascending aorta is a common finding in Tetralogy of fallot (TOF). We sought to provide aortic dimensions in children and adolescents after corrected TOF obtained by contrast-enhanced cardiac-magnetic-resonance angiography (CE-CMRA) that could serve as reference values.

Materials and methods

We enrolled 101 children and adolescents (56 male) with a median age of 10.9 years. All patients underwent CE-CMRA imaging using a 3-dimensional spoiled gradient-echo-sequence. Aortic diameters were measured at the level of the aortic valve (AV), aortic sinus (AS), sino-tubular junction (STJ) and the ascending aorta (AA) and compared with normal values obtained from literature. Sex-specific aortic dimensions are given as percentile curves as well as z scores. Furthermore CMR volumetric and functional parameters as well as clinical and anamnestic data were analyzed to identify parameters that are associated with aortic dilatation.

Results

Diameters for aortic size for males were 3.6 + 16.6*BSA^0.5 at the AV level, 7.0 + 19.5*BSA^0.5 at the AS level, 7.0 + 14.4*BSA^0.5 at the STJ level and 7.3 + 15.5*BSA^0.5 at the AA level. Diameters for females were 5.8 + 14.1*BSA^0.5 at the AV level, 7.2 + 17.6*BSA^0.5 at the AS level, 5.2 + 15.4*BSA^0.5 at the STJ level and 2.0 + 17.8*BSA^0.5 at the AA level. All diameters in TOF patients were larger compared with normal values. The postoperative interval and age at examination were the only parameters associated with aortic size at all measured levels.

Conclusion

We provide CE-CMRA data of aortic dimensions in children and adolescents after correction of TOF. Our data might be useful for an estimation of the “normal” aortic size in this patient cohort and can serve as a basis for future longitudinal studies adding prognostic data.

Aortic wrapping for a dilated ascending aorta in bicuspid aortic stenosis

BACKGROUND

Ascending aorta wrapping is rarely recommended for the management of dilated aorta, because of late complications. The aim of the present study was to analyze the early and late outcomes of the aortic wrapping technique at the time of aortic valve replacement (AVR) for bicuspid aortic stenosis (BAS).

METHODS AND RESULTS

Among patients who underwent primary AVR for BAS between 2002 and 2011, 79 who underwent ascending aortic wrapping (wrapping group) were compared with 144 patients who underwent AVR alone. The preoperative ascending aortic diameters were larger in the wrapping group (40.9±4.2 mm vs. 48.6±4.0 mm, P<0.001). Operative technique was to wrap the ascending aorta transversely with a semi-elliptically resected Dacron graft. The follow-up for the wrapping group was 76.5±35.5 (median 71.1) months. There were no early deaths. Early and late morbidity did not differ between groups. The 24 late deaths, including 10 cardiac-related deaths, occurred in the entire group; 3 sudden deaths occurred only in the AVR group. The 10-year overall survival in the wrapping group was higher than the AVR group (88.1±6.8% vs. 80.0±4.6%, P=0.048). No late aortic complications were detected. The aortic diameter was reduced from 49.5±4.1 mm to 45.3±5.0 mm after wrapping (P<0.001).

CONCLUSIONS

The aortic wrapping technique may be an option for treating a moderately dilated ascending aorta in selected patients undergoing AVR for BAS. Longer follow-up, however, is necessary to verify later complications.