Surveillance Recommendations after Thoracic Endovascular Aortic Repair Should Be Based on Initial Indication for Repair

Low rates of aortic surveillance imaging and clinical follow-up in patients with acute aortic dissection

OBJECTIVE

Patients that survive acute aortic dissection (AD) remain at high risk of morbidity/mortality from structural changes of the aorta. Aortic surveillance is challenging, especially within a tertiary referral center. Our aim was to identify follow-up imaging and appointment rates, and factors associated with incomplete surveillance in patients with acute AD.

METHODS

This was a single-center, retrospective study of acute AD patients at a tertiary care center from July 2012 to December 2022 who lived at least 1 year after AD. We defined complete surveillance as having computed tomography scans or magnetic resonance imaging scans of the chest and abdomen at 1 month (±14 days), 6 months (±1.5 months), 1 year (±3 months), and yearly thereafter. Data were obtained from the electronic health record. Predictors of absent imaging at the 1 year (±3 months) timepoint were evaluated using multivariable logistic regression.

RESULTS

Of the 272 patients in the study, 63.2% were male and 39.3% were White. The average age was 60.7 ± 14.7 years. Acute type A AD comprised 47.1% of our cohort; 91.4% underwent open repair within 1 week of presentation. Of the acute type B AD patients (52.9% of the cohort), 41.7% underwent thoracic endovascular aortic repair at the index admission. At the 1-year follow-up interval (±3 months), 26.5% were confirmed to have undergone aortic surveillance imaging, and 27.6% had an appointment with a cardiovascular specialist. Only 9.6% of the cohort was fully concordant with the recommended surveillance imaging in the first year of follow-up. On multivariate regression, non-English speakers (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.05-3.99; P = .03) and residence outside of hospital region (OR, 1.66; 95% CI, 1.02-3.17; P = .04) were independently-associated with lack of follow-up imaging at the 1-year timepoint, whereas longer length of stay was independently-associated with completed imaging at the 1-year timepoint (OR, 0.78; 95% CI, 0.41-0.89; P = .04).

CONCLUSIONS

This study highlights a low rate of surveillance and clinical follow-up for patients with acute AD and a significant disparity for non-English speaking patients and those who reside outside of the hospital region. This information should inform future quality initiatives to improve aortic surveillance following AD.

Aggressive Treatment Strategy at Index Thoracic Endovascular Aortic Surgery is Associated with Reduced Need for Short-Term Reintervention in Patients with Aortic Dissection

INTRODUCTION

Thoracic endovascular aortic surgery (TEVAR) is the modern standard of treatment for patients with Type B aortic dissection, however it is unclear how the initial length of treated aorta affects long-term outcomes. This study aims to elucidate risk factors for secondary intervention after TEVAR for aortic dissection, focusing on length of aortic treatment at index operation.

METHODS

A retrospective multihospital chart review was completed for patients treated between 2011 and 2022 who underwent TEVAR for aortic dissection with at least 1 year of post-TEVAR imaging and follow-up. Patient demographics and characteristics were analyzed. In this study, aortic zones treated only included those managed with a covered stent graft. The primary outcome measure was any need for secondary intervention.

RESULTS

A total of 151 patients were identified. Demographics included a mean age of 57 years, with 31.8% of the patients being female. Forty-three patients (28.5%) underwent secondary intervention after TEVAR, with a mean follow-up of 1.6 years. The most common indication for secondary intervention was aneurysmal degeneration of the residual false lumen (76%). There was a significant difference in the number of aortic zones treated in patients who did and did not require secondary intervention (2.3 ± 1 vs. 2.7 ± 1, P = 0.04). Additionally, patients with 3 or more aortic zones of treatment had a significant difference in the need for reintervention (32% secondary intervention versus 52% no secondary intervention, P = 0.02).

CONCLUSIONS

At least 3 zones of aortic treatment at index TEVAR is associated with a decreased need for overall reintervention. Modern treatment of acute and subacute type B dissection should stress an aggressive initial repair, balanced by the potential increased risk of spinal cord ischemia.

The Value of Aortic Volume and Intraluminal Thrombus Quantification for Predicting Aortic Events after Endovascular Thoracic Aneurysm Repair

Objectives: To assess the ability of the aortic aneurysm volume (AAV), aneurysmal lumen volume (ALV), and aneurysmal thrombus volume (ATV) to predict the need for aortic reintervention when using the maximal aortic diameter as a reference. Methods: This monocentric retrospective study included 31 consecutive patients who underwent successful thoracic endovascular aortic repair (TEVAR) to treat an atheromatous thoracic aortic aneurysm. All patients underwent clinical and computed tomography angiography (CTA) for 3 years after TEVAR. The patients were categorized into group 0 if no aortic reintervention was required during the follow-up period and categorized into group 1 if they experienced a type I or III endoleak or aneurysm diameter increase requiring intervention. The maximum aneurysm sac diameter and the AAV, ALV, and ATV were calculated using CTA images obtained preoperatively (T0) and at 6-12 months (T1), 24 months (T2), and 36 months (T3) postoperatively, and their changes over time were analyzed. Correlations between diameter and changes in AAV, ALV, and ATV were assessed, and the association between diameter and volume changes and reintervetion was examined. The cutoff values for predicting the need for reintervention was determined using a receiver operating characteristic (ROC) curve. The accuracy of volume change versus diameter change for predicting the need for reintervention was analyzed. Results: There were no significant differences in terms of the mean aneurysm diameter or AAV, ALV or ATV between the groups at preoperative CTA or after one year of follow-up imaging. The mean ATV was higher in group 1 than in group 0 at 2 years (187.6 ± 86.3 mL vs. 114.7 ± 64.7 mL; p = 0.057) and after 3 years (195.0 ± 86.7 mL vs. 82.1 ± 39.9 mL; p = 0.013). The maximal diameter was greater in group 1 than in group 0 at 3 years (67.3 ± 9.5 mm vs. 55.3 ± 12.6 mm; p = 0.044). The rate of AAV change between T0 and T1 was significantly higher in group 1 (7 ± 4.5%) than in group 0 (-6 ± 6.8%; p < 0.001). The rate of ATV change between T1-T3 was significantly higher in group 1 than in group 0 (34 ± 40.9% vs. -13 ± 14.4% (p = 0.041)); similar results were observed for the rate of ATV change between T2 and T3 (27 ± 50.1% for group 1 vs. -8 ± 49.5% in group 0 (p < 0.001)). According to our multivariate analysis, the annual growth rate for AAV between T0 and T1 was the only independent factor that was significantly associated with aortic reintervention (area under the curve (AUC) = 0.84, OR = 1.57, p = 0.025; optimal cutoff +0.4%). An increase in the annual growth rate of the ATV between T0 and T3 was independently associated with the need for aortic reintervention (area under the curve (AUC) = 0.90, OR = 1.11, p = 0.0347; optimal cutoff +10.1%). Conclusions: Aortic volume analysis can predict the need for aortic reintervention more accurately and earlier than maximal aortic diameter.

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

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Descending thoracic aortic emergencies: Past, present, and future

The most important descending thoracic aortic (DTA) pathologies are aneurysms, dissections, and traumatic injuries. In acute settings, these conditions can constitute a significant risk of bleeding or ischemia of vital organs, resulting in a fatal outcome. Morbidity and mortality associated with aortic pathologies remain significant, despite improvements in medical therapy and endovascular techniques. In this narrative review, we present an overview of the transitions in the management of these pathologies and discuss current challenges and future perspectives. Diagnostic challenges include differentiating between thoracic aortic pathologies and cardiac diseases. Efforts have been made to identify a blood test that can rapidly differentiate these pathologies. Computed tomography is the cornerstone of diagnosing thoracic aortic emergencies. Our understanding of DTA pathologies has improved substantially due to the significant advancement in imaging modalities in the last 2 decades. On the basis of this understanding, the treatment of these pathologies has been revolutionized. Unfortunately, robust evidence from prospective and randomized studies is still lacking for the management of most DTA diseases. Medical management plays a crucial role in achieving early stability during these life-threatening emergencies. This includes intensive care monitoring, heart rate and blood pressure control, and considering permissive hypotension for patients presenting with ruptured aneurysms. Over the years, surgical management of DTA pathologies changed from open repair to endovascular repair with dedicated stent-grafts. Techniques in both spectrums have improved substantially.

Males and females have similar mortality after thoracic endovascular aortic repair for blunt thoracic aortic injury

OBJECTIVE

Prior literature has demonstrated worse outcomes for female patients after abdominal aortic aneurysm repair. Also, prior studies in the context of thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysms have reported conflicting results regarding sex-related outcomes. Because the influence of sex on the outcomes after TEVAR for blunt thoracic aortic injuries (BTAIs) remains understudied, we evaluated the association between sex and outcomes after TEVAR for BTAI.

METHODS

We identified patients who had undergone TEVAR for BTAIs in the Vascular Quality Initiative registry from 2013 to 2022 and included those who had undergone TEVAR within zones 2 to 5 of the thoracic aorta. Patients with missing information regarding the aortic injury grade (Society for Vascular Surgery aortic injury grading system) were excluded. We performed multivariable logistic regression and Cox regression to determine the influence of sex on the perioperative outcomes and long-term mortality, respectively.

RESULTS

We identified 1311 patients, of whom 27% were female. The female patients were significantly older (female, 47 years [interquartile range (IQR), 30-63 years]; male, 38 years [IQR, 28-55 years]; P < .001) with higher rates of comorbidities. Although the female patients had had higher Glasgow coma scale scores (median, 15 [IQR, 11-15]; vs 14 [IQR, 8-15]; P = .028), no differences were found in the aortic injury grade or other coexisting traumatic injuries between the sexes. Apart from the longer procedure duration for the female patients (median, 79 minutes [IQR, 52-119 minutes]; vs 69 minutes [IQR, 48-106 minutes]; P = .008), the procedural characteristics were comparable. After adjustment, no significant association was found between female sex and perioperative mortality (7.1% vs 8.1%; odds ratio, 0.76; 95% confidence interval [CI], 0.43-1.3; P = .34). The male and female patients had had comparable rates of postoperative complications (26% vs 29%; odds ratio, 0.89; 95% CI: 0.52-1.5]; P = .26) including access-related complications (0.5% vs 0.8%; P=.83). However, females had a significantly higher risk for reintervention during the index admission (odds ratio, 2.5; 95% CI, 1.1-5.5; P = .024). No significant difference was found between the male and female patients with respect to 5-year mortality (hazard ratio, 0.87; 95% CI, 0.57-1.35; P = .50).

CONCLUSIONS

Unlike the sex-based outcome disparities observed after thoracic aortic aneurysm repair, we found no significant association between sex and perioperative outcomes or long-term mortality after TEVAR for BTAIs. This contrast in the sex-related outcomes after other vascular pathologies might be explained by differences in the pathology, demographics, and anatomic factors in these patients.

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

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

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

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.