Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial

Trends and Updates in the Management and Outcomes of Acute Uncomplicated Type B Aortic Dissection

Type B aortic dissection (TBAD) presents a complex clinical challenge requiring coordinated, multidisciplinary care to optimize patient outcomes. While rapid intervention is crucial for complicated TBAD, the optimal management of uncomplicated cases remains less well-defined. Historically, uncomplicated TBAD was managed medically, but recent years have seen a shift toward selective interventional approaches. Updated American and European guidelines now recommend thoracic endovascular aortic repair (TEVAR) for high-risk, uncomplicated cases, characterized by factors including a large aortic diameter, large entry tears, or persistent pain. Observations from the International Registry of Acute Aortic Dissection highlight a significant shift toward endovascular management and reduced mortality over time. The acute dissection stentgraft or best medical treatment and investigation of stent grafts in aortic dissection trials suggested that pre-emptive TEVAR may benefit certain high-risk patients by promoting favorable aortic remodeling. However, routine use of TEVAR in all uncomplicated cases is presently still controversial due to risks such as stroke and spinal cord ischemia, which emphasize the importance of careful patient selection. Current evidence supports a tailored approach that integrates clinical and imaging risk factors to identify patients most likely to benefit from pre-emptive TEVAR. In addition, ongoing randomized controlled trials, including IMPROVE-AD, SUNDAY, and EARNEST, will hopefully provide critical data on the risks and benefits of TEVAR in uncomplicated TBAD. Moving forward, interdisciplinary collaboration among different medical and engineering specialties, and refined risk stratification will be essential to advance TBAD management, enhancing outcomes for both complicated and uncomplicated cases.

Proximal Aortic Landing Zone Dilation Following Thoracic Endovascular Aortic Repair for Type B Aortic Dissection: Incidence and Clinical Implications

BACKGROUND

This study aimed to assess the incidence, predictors, and clinical relevance of proximal aortic landing zone dilation (PALD) following thoracic endovascular aortic repair (TEVAR) for acute and chronic type B aortic dissection (TBAD).

METHODS

A retrospective analysis of 47 patients who underwent TEVAR for TBAD at a single center was conducted. PALD was defined as a ≥5 mm increase in aortic diameter at 2 of 3 measurement sites (at 0, 1, and 2 cm distal to the stent graft proximal edge) at postoperative computed tomography angiography. The primary endpoint was the development of PALD. Secondary endpoints included entry fIow type IA, device migration and reintervention rates. Kaplan-Meier analyses was used to evaluate PALD-free survival.

RESULTS

PALD occurred in 19% of patients (n = 9) during a median follow-up of 62 months. A stent graft diameter >36 mm significantly predicted PALD (P = 0.022), with an area under the curve of 0.75 (sensitivity: 89%, specificity: 58%). No significant associations were found between PALD and reinterventions or type Ia entry flow. Kaplan-Meier analysis revealed a median PALD-free survival of 156 months (95% confidence interval: 92-210). Patients with PALD demonstrated a greater increase in aortic diameter at maximum follow-up compared to non-PALD patients (P < 0.001). Other demographic, anatomic, and procedural factors were not associated with PALD, and especially oversizing did not correlate with PALD development.

CONCLUSION

PALD occurred in a significant proportion of patients following TEVAR for TBAD, with stent graft diameter serving as key predictor. PALD did not correlate with adverse clinical outcomes in this cohort.

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.

Endovascular Treatment Options for Chronic Dissections

Aortic dissections are classified based on the location of the entry tear. A major concern in chronic aortic dissections is aneurysmal degeneration. Aneurysmal degeneration can lead to aortic expansion and potentially death. False lumen patency is a predictor of outcomes in type B aortic dissections. Thoracic endovascular aortic repair (TEVAR) can be used to treat chronic aortic dissections. TEVAR aims to occlude the false lumen to promote thrombosis and favorable aortic remodeling. However, its benefit may be limited in chronic dissection. Several techniques have been developed to treat chronic dissections with TEVAR.

Early Thoracic Endovascular Aortic Repair for Acute Type B Dissection Is Associated with Increased Complications: Results from the Gore Global Registry for Endovascular Aortic Treatment Registry

BACKGROUND

Several recent small trials have suggested that there is a potential benefit of early thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), even for uncomplicated patients. We studied patients enrolled in the Gore Global Registry for Endovascular Aortic Treatment (GREAT) to compare outcomes of TEVAR in the early-acute phase with and without complicated presentation.

METHODS

The GREAT registry was queried for patients treated with TEVAR for TBAD. Acute phase of TBAD was defined as hospitalization within 14 days of symptom onset. Time to treatment was computed as time from first symptoms to time of TEVAR implantation regardless of the preoperative duration of hospitalization. Complicated presentation of acute TBAD was designated by the treating clinical sites, and treatment strategy was determined at the physician's discretion, as was common practice at the time of registry conception in 2010; therefore, the designation of "complicated" presentation in this study differs from the most recent Society for Vascular Surgery/Society of Thoracic Surgeons reporting standards, which refers exclusively to malperfusion and rupture. All patients received TEVAR with Gore TAG or CTAG devices (W.L. Gore & Associates, Flagstaff, Arizona). The primary exposure variable was time from symptom onset to TEVAR, stratified by complicated versus uncomplicated presentation. The primary outcome was postoperative aortic complications, defined as endoleak, extended or new dissection (including retrograde type A dissection), rupture, enlargement or aneurysmal degeneration, requirement for reinterventions, conversion to open repair, and graft infection. Univariate data were analyzed by contingency table and unpaired t-test or Wilcoxon rank sum, and adjusted analyses were conducted using stratified and multiple logistic and Cox regression techniques. Data were analyzed by an independent academic research team.

RESULTS

Of the 5,014 patients enrolled in the GREAT registry between 2011 and 2016, there were 172 patients who received TEVAR for TBAD; 40 of 172 (23%) were female and the mean age was 61 ± 12 years. There were 102 (59%) with complicated presentations. After adjustment for complicated presentation, TEVAR performed within 3 days of symptom onset was independently associated with increased rate of short-term (odds ratio, 2.4, P < 0.039), and intermediate-term (hazard ratio 2.31, P < 0.024) aortic complications. TEVAR performed within 3 days was also associated with increased rates of aortic reinterventions, branch vessel complications, renal complications, and aortic complication/death at 6 months when compared with delayed repair.

CONCLUSION

These data suggest that TEVAR performed at least 3 days after acute TBAD is associated with less morbidity and mortality. When possible, TEVAR should be delayed by at least 3 days for patients with uncomplicated acute TBAD to offer maximum risk reduction.

Mechanisms of aortic dissection: From pathological changes to experimental and in silico models

Aortic dissection continues to be responsible for significant morbidity and mortality, although recent advances in medical data assimilation and in experimental and in silico models have improved our understanding of the initiation and progression of the accumulation of blood within the aortic wall. Hence, there remains a pressing necessity for innovative and enhanced models to more accurately characterize the associated pathological changes. Early on, experimental models were employed to uncover mechanisms in aortic dissection, such as hemodynamic changes and alterations in wall microstructure, and to assess the efficacy of medical implants. While experimental models were once the only option available, more recently they are also being used to validate in silico models. Based on an improved understanding of the deteriorated microstructure of the aortic wall, numerous multiscale material models have been proposed in recent decades to study the state of stress in dissected aortas, including the changes associated with damage and failure. Furthermore, when integrated with accessible patient-derived medical data, in silico models prove to be an invaluable tool for identifying correlations between hemodynamics, wall stresses, or thrombus formation in the deteriorated aortic wall. They are also advantageous for model-guided design of medical implants with the aim of evaluating the deployment and migration of implants in patients. Nonetheless, the utility of in silico models depends largely on patient-derived medical data, such as chosen boundary conditions or tissue properties. In this review article, our objective is to provide a thorough summary of medical data elucidating the pathological alterations associated with this disease. Concurrently, we aim to assess experimental models, as well as multiscale material and patient data-informed in silico models, that investigate various aspects of aortic dissection. In conclusion, we present a discourse on future perspectives, encompassing aspects of disease modeling, numerical challenges, and clinical applications, with a particular focus on aortic dissection. The aspiration is to inspire future studies, deepen our comprehension of the disease, and ultimately shape clinical care and treatment decisions.

Midterm outcomes of thoracic endovascular aortic repair versus optimal medical therapy for uncomplicated acute type B dissection

Objective

We sought to compare the early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) versus optimal medical therapy (OMT) for uncomplicated acute type B aortic dissection.

Methods

Data were analyzed for 200 consecutive patients with uncomplicated acute type B aortic dissection from February 1992 to July 2022, including 147 with initial OMT and 53 undergoing TEVAR at index hospitalization. Baseline, intraoperative, and postoperative data, survival, and (re)intervention were compared between the two strategies.

Results

In-hospital/30-day mortality was 7.5% (15/200) for the entire series, which was significantly lower in the TEVAR group compared with the OMT group (0 vs 10.2% [15/147]; P = .013). Thirty-day rates were 5.7% (3/53) for reintervention after TEVAR and 15.6% (23/147) for intervention after OMT (P = .064). Death within 30 days of (re)intervention was 0 (n = 0) in the TEVAR group and 18.4% (n = 14) in the OMT group (P = .063). There were no significant differences in the incidences of stroke, paraplegia, acute kidney injury, sepsis, or malperfusion syndrome after initial treatment. Kaplan-Meier survival in the TEVAR group was 92.3% (95% CI, 80.7-97.0) at 1 year and 3 years, significantly higher than in the OMT group (80.3% [95% CI, 72.8-85.8] and 71.4% [95% CI, 63.4-78.0]; P = .012). In patients aged 65 years or more, TEVAR also achieved a significantly higher survival, which was 93.7% (95% CI, 77.5-98.3 vs 69.7% [95% CI, 58.0-78.7]) at 1 year and 93.7% (95% CI, 77.3-98.3] vs 60.5% [95% CI, 48.7-70.5]) at 3 years (P < .001).

Conclusions

In this single-institution experience, upfront TEVAR performed at index hospitalization for uncomplicated acute type B aortic dissection was associated with improved survival at early and midterm follow-up.

Real-world outcomes and management trends in uncomplicated type B aortic dissection

OBJECTIVES

Uncomplicated type B aortic dissection (uTBAD) accounts for a significant proportion of TBAD cases, but large-scale data on their prognosis remain limited. This study aims to evaluate real-world management and outcomes of uTBAD.

METHODS

Patients aged 20 or older admitted for acute TBAD between 1 April 2013 and 30 September 2020 were included in the analysis set. They were classified as uTBAD 1 month after admission. Data were sourced from the Shizuoka Kokuho Database, a regional claims database. The primary outcomes were all-cause mortality and aortic events (death, type A dissection, rupture or surgery). Cumulative event rates were estimated using the Kaplan-Meier method. Outcomes of patients treated with thoracic endovascular aortic repair (TEVAR) versus medical therapy were compared using inverse probability weighting.

RESULTS

A total of 1292 uTBAD patients were identified. Sixty-seven patients underwent TEVAR within 12 months, with a cumulative TEVAR rate of 5.4%. The cumulative mortality was significantly higher in comparison to the age- and sex-adjusted general population (1 year: 15.0% vs 6.7%, 3 years: 28.6% vs 18.6%, P < 0.001). Aortic events occurred in 22.1%, 30.0% and 36.7% at 1, 2 and 3 years, respectively. TEVAR within 12 months was associated with a trend towards lower mortality (adjusted hazard ratio 0.53, 95% confidence interval 0.27-1.04) and fewer aortic events (adjusted hazard ratio 0.54, 95% confidence interval 0.29-1.01) compared to medical therapy.

CONCLUSIONS

uTBAD patients have poorer survival and higher rates of aortic events compared to the general population. TEVAR within 12 months can potentially improve patient outcomes.

Initial aortic repair versus medical therapy for early uncomplicated type B dissections

BACKGROUND

Uncomplicated type B aortic dissections was regarded benign and treated with optimal medical therapy (OMT). However, studies showed highly unpredictable of disease progression, which suggested the need of earlier intervention. To search for features associated with worse outcomes with OMT is important due to risk of intervention. We investigated mortality and aortic remodeling between aggressive (OMT and pre-emptive endovascular intervention) and conservative therapy (OMT and necessary operations).

METHODS

Retrospective analysis was performed in acute and subacute uncomplicated type B dissections patients, including typical aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer, diagnosed between June 2005 and May 2021. Patients with Marfan, traumatic, iatrogenic, zone 0 (ascending aorta) involvement, and maximal aortic diameter > 45mm were excluded. Patients are classified according to initial management.

RESULTS

77 and 33 patients in the aggressive and conservative groups were included respectively. There was no differences in baseline clinical and radiological characteristics between them. During mid-term follow-up (median 62.5 months), there was no difference in the mortality but the incidence of 30-day acute kidney injury was significantly higher in aggressive group. Positive aortic remodeling was noted in aggressive group, with development to complete or incomplete false lumen thrombosis (p < 0.01).

CONCLUSION

Aggressive pre-emptive endovascular therapy though has acceptable outcomes and positive aortic remodelling in early uncomplicated type B dissection with maximal aortic diameter ≤ 45mm. However, it could not translate into better mid-term survival than conservative therapy, but with higher risk of 30-day acute kidney injury. Aggressive pre-emptive endovascular intervention should be cautious in these patients.

Thirty-Day Endovascular Repair Outcomes of Stanford Type B Aortic Dissection in Patients With Diabetes Mellitus: A Propensity-Score-Matched Study From the ACS-NSQIP Database

BACKGROUND

The surgical intervention for Stanford type B aortic dissection (TBAD) has been revolutionized by thoracic endovascular aortic repair (TEVAR). While diabetes mellitus (DM) is associated with increased risks of short-term mortality and infectious complications after major surgeries, previous studies present conflicting findings regarding the outcomes of TEVAR in DM patients. This study aimed to assess the 30-day postoperative outcomes for DM patients who have undergone TEVAR for TBAD using a dataset from a multi-institutional national registry.

METHODS

Patients who underwent TEVAR for TBAD were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2022. A 1:4 propensity-score matching was used to balance demographics and preoperative characteristics between patients with and without DM. Thirty-day postoperative outcomes were compared.

RESULTS

There were 160 (8.89%) DM and 1640 (91.11%) non-DM patients who underwent TEVAR for TBAD. After propensity-score matching, all DM patients were matched to 594 non-DM patients. DM patients had a higher rate of mortality that was trending toward significance (10.19% vs 5.89%, p = 0.07). All 30-day complications were comparable between DM and non-DM patients.

CONCLUSION

TEVAR can generally be safe for DM patients in terms of short-term outcomes, but the potential for higher perioperative mortality rates in these patients may warrant careful consideration. Further large-scale studies may be necessary to fully understand the impact of DM on both short-term and long-term outcomes following TEVAR for TBAD.Clinical ImpactThis study assessed the 30-day postoperative outcomes for diabetes mellitus (DM) patients who have undergone thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. After propensity-score matching, DM patients had a higher rate of mortality that was trending toward significance but all 30-day complications were comparable between DM and non-DM patients. Therefore, TEVAR can generally be safe for DM patients in terms of short-term outcomes, but the potential for higher perioperative mortality rates in these patients may warrant careful consideration. Further large-scale studies may be necessary to fully understand the impact of DM on both short-term and long-term outcomes following TEVAR for TBAD.

Type A Aortic Dissection After Thoracic Endovascular Aortic Repair for Type B

Type A aortic dissection (TAAD) has been associated with thoracic endovascular aortic repair (TEVAR) for aortic conditions: dissection and aneurysm. Our purpose was to study a subset of patients who had an initial TEVAR for type B aortic dissection, followed by a TAAD, which was treated by open ascending aortic repair. Over a 6-year period, 171 consecutive patients underwent open ascending aortic repair for TAAD, of whom 21 (12%) had a previous cardiovascular procedure, 17 of which were endovascular. A total of 9 (5.2%) of 171 patients with TAAD had a previous TEVAR for a type B. The mean interval from TEVAR to open ascending aortic repair for TAAD was 4.6 years, with only 1 occurring within a month. Only 1 patient had abnormal aortic media by histology. In 5 of the 9 patients, the entry tear was in the proximal ascending aorta, remote from the endograft, which suggests that a TAAD late after TEVAR for type B represents a new spontaneous event.

Comparisons of open surgical repair, thoracic endovascular aortic repair, and optimal medical therapy for acute and subacute type B aortic dissection: a systematic review and meta-analysis

BACKGROUND

Various treatments have been employed in managing type B aortic dissection (TBAD), encompassing open surgical repair (OSR), thoracic endovascular aortic repair (TEVAR), and optimal medical therapy (OMT). Nonetheless, the determination of the most efficacious treatment protocol remains a subject of debate. We aim to compare the treatments in patients with acute and subacute TBAD using a meta-analytic approach.

METHODS

A systematic search was conducted across databases including PubMed, EmBase, and the Cochrane Library for relevant studies published from their inception up to September 2024. Studies comparing OSR, TEVAR, and OMT for TBAD through controlled or direct comparative designs were incorporated. Pairwise comparison meta-analyses were performed employing odds ratios (OR) alongside 95% confidence intervals (CIs) to quantify intervention effects by using the random-effects model.

RESULTS

Thirty-one studies involving 34,681 patients with TBAD were included in the final meta-analysis. We noted OSR were associated with an increased risk of in-hospital mortality (OR: 2.41; 95%CI: 1.67-3.49; P < 0.001), paraplegia (OR: 3.60; 95%CI: 2.20-5.89; P < 0.001), limb ischemia (OR: 7.80; 95%CI: 2.39-25.49; P = 0.001) and bleeding (OR: 9.54; 95%CI: 6.57-13.85; P < 0.001) as compared with OMT. Moreover, OSR versus TEVAR showed an increased risk of in-hospital mortality (OR: 2.67; 95%CI: 1.92-3.72; P < 0.001), acute renal failure (OR: 1.98; 95%CI: 1.61-2.42; P < 0.001), myocardial infaraction (OR: 2.76; 95%CI: 1.64-4.65; P < 0.001), respiratory failure (OR: 2.19; 95%CI: 1.73-2.76; P < 0.001), or bleeding (OR: 1.88; 95%CI: 1.33-2.67; P < 0.001), and lower risk of reintervention (OR: 0.30; 95%CI: 0.10-0.89; P = 0.030). Finally, TEVAR was associated with an increased risk of stroke (OR: 1.77; 95%CI: 1.41-2.21; P < 0.001), limb ischemia (OR: 13.00; 95%CI: 4.33-39.06; P < 0.001), and bleeding (OR: 3.65; 95%CI: 2.40-5.55; P < 0.001) as compared with OMT.

CONCLUSIONS

This study systematically compared various treatments and showed their safety and efficacy for acute and subacute TBAD. The results require further large-scale randomized controlled trials.

Optimal timing of thoracic endovascular aortic repair for subacute and chronic type B aortic dissection: insights from the Tokushukai Medical Database†

OBJECTIVES

This study aimed to evaluate the impact of intervention timing on thoracic aortic remodelling following thoracic endovascular aortic repair (TEVAR) for subacute and chronic type B aortic dissection (TBAD).

METHODS

The study included 110 patients undergoing TEVAR for TBAD at least 2 weeks after onset, sourced from the Tokushukai Medical Database. The primary outcome was complete thoracic aortic remodelling (CTR) at 1 year, defined as thoracic false lumen thrombosis and a false lumen diameter <10 mm up to the level of Th10.

RESULTS

The 1-year CTR rate was 67.3%. CTR was strongly associated with intervention timing: 88.4% (≤3 months: n = 69), 57.1% (3-12 months: n = 14) and 18.5% (≥12 months: n = 27). Receiver operating characteristic (ROC) curve analysis confirmed a 3-month cutoff for achieving CTR (area under the curve 0.857). Multivariable analysis identified interval from onset to TEVAR >3 months (odds ratio [OR] 9.75, 95% confidence interval [CI] 2.86-33.28) and initial thoracic false lumen diameter (OR 1.13, 95% CI 1.02-1.27) as independent predictors of CTR failure. Similar trends were observed in the DeBakey IIIb subgroup, with a 3-month cutoff for achieving CTR and interval from onset to TEVAR >3 months (OR 16.38, 95% CI 3.54-75.83), initial thoracic false lumen diameter (OR 1.25, 95% CI 1.00-1.54) and initial abdominal aortic diameters (OR 1.14, 95% CI 1.01-1.29) predicting CTR failure.

CONCLUSIONS

Early TEVAR within 3 months of onset is crucial for achieving complete aortic remodelling in TBAD. Therefore, early preventive TEVAR in eligible patients is recommended to optimize outcomes.

Questions and Certainty in Diagnosis and Management of Acute Type B Aortic Dissection

Type B aortic dissection (TBAD) is a severe cardiovascular condition that requires timely diagnosis and intervention to prevent life-threatening complications. The aim of this review was to focus on the most crucial and controversial aspects of contemporary TBAD management. It is recognized that in the acute phase, computed tomography angiography (CTA) plays an essential role in evaluating the extent of the dissection and monitoring disease progression. CTA has significantly improved the management of TBAD by providing detailed assessments of aortic anatomy and dynamic flow changes, positioning it as the cornerstone imaging modality for identifying acute high-risk patients who may require early intervention. Recently, new advances in magnetic resonance imaging (MRI) and positron emission tomography (PET) technology have the potential to provide further information beyond imaging alone. However, such sophisticated techniques should be reserved for stable patients after the acute phase. After decades of medical therapy and high risk surgery, thoracic endovascular aortic repair (TEVAR) has emerged as a minimally invasive alternative to open surgery for complicated TBAD, offering lower perioperative morbidity and mortality. Nevertheless, its use in uncomplicated TBAD remains a topic of ongoing debate. While recent studies suggest that preemptive TEVAR combined with optimal medical therapy may reduce late adverse events and improve long-term outcomes, these findings remain controversial. This review critically analyzes the current literature on both diagnosis and TEVAR treatment, evaluating these controversies in the context of clinical practice.

Long-Term Volumetric Evaluation of Stent-Assisted Balloon-Induced Intimal Disruption and Relamination of Aortic Dissection (STABILISE) in Acute Type B Aortic Dissection

BACKGROUND

To quantify the volumetric aortic remodeling of patients with acute type B aortic dissection treated with the stent-assisted balloon-induced intimal disruption and relamination (STABILISE) technique.

METHODS

All patients with acute type B aortic dissection operated with the STABILISE technique between 2014 and 2017 with preoperative, postoperative, and >12 months (follow-up) computed tomography scans were included in this study. True lumen and total aortic volume were accurately assessed in the thoracic and abdominal portions with a semiautomatic three-dimensional tool. Associations with long-term adverse events were estimated.

RESULTS

Seventeen patients were measured at preoperative, postoperative, and a mean follow-up of 19 ± 8 months. The false lumen to total volume ratio decreased on average from 63% to 18% after STABILISE (P < 0.001) and remained around 12% at follow-up. These remodeling was more pronounced in the thoracic aorta (7%) than in the abdominal aorta (28%). The trend in aortic size growth was stronger for volumes than for maximum areas or diameters (P < 0.001, P < 0.05, and P < 0.05, respectively). Adverse events were identified in 4 patients during a long-term follow-up of 76 ± 18 months. The only aortic size variable assessed preoperatively that was associated with undesirable events was the total volume of the abdominal aorta (P < 0.05).

CONCLUSIONS

A volumetric analysis of dissected aortic size after the STABILISE procedure allowed accurate quantification of mid-term aortic remodeling and helped to identify the abdominal aortic volume as a preoperative variable associated with undesirable long-term events.

Long-Term Outcomes of Endovascular Repair of Thoracic Aortic Aneurysms

The thoracic aorta is a dynamic structure composed of the aortic root, ascending aorta, aortic arch, and descending aorta. It is subject to the pressure and volume of the cardiac cycle and susceptible to atherosclerotic and aneurysmal changes. With these changes, the risk for acute aortic syndromes increases, thus creating the impetus for earlier interventions. The previous standard of open surgical repair has undergone a transition in recent years toward endovascular repair being favored in the descending and abdominal aortas with ongoing investigation into approaches for the ascending and aortic arch. These therapies have been shown to improve early mortality and morbidity outcomes with the caveat of more interventions compared with open surgery. We undertook this review to analyze the current data available regarding long-term outcomes in patients undergoing endovascular repair for thoracic aortic disease. The data support long-term benefit of endovascular repair for thoracic aortic disease. The primary indications identified for reintervention are endoleak and further aneurysmal degeneration. As the devices available for endovascular repair evolve, ongoing review of these outcomes will be necessary. It will also be important to trend the results as further techniques become available for endovascular repair of the ascending aorta and aortic arch.

Thirty-day outcomes of endovascular repair of Stanford type B aortic dissection in patients with chronic obstructive pulmonary disease

BACKGROUND

Thoracic Endovascular Aortic Repair (TEVAR) has revolutionized the surgical treatment for Stanford type B aortic dissection (TBAD). While chronic obstructive pulmonary disease (COPD) is associated with worse outcomes in major surgeries, the specific outcomes of TEVAR in patients with COPD have not been extensively explored. This study aimed to evaluate the 30-day postoperative outcomes of COPD patients undergoing TEVAR for TBAD utilizing data from a multi-institutional national registry.

METHODS

Patients who underwent TEVAR for TBAD were identified in the ACS-NSQIP database from 2005 to 2022. A 1:3 propensity-score matching was used to match demographics and preoperative characteristics between patients with and without COPD. Thirty-day postoperative outcomes were compared.

RESULTS

There were 172 (9.56%) and 1628 (90.44%) COPD and non-COPD patients who underwent TEVAR for TBAD, respectively. Patients with COPD had a higher comorbidity burden. After the propensity-score matching, all 172 COPD patients were matched to 440 non-COPD patients. COPD and non-COPD patients had comparable mortality rates (10.12% vs 6.82%, p = .18). However, COPD patients had a higher risk of pulmonary complications (20.83% vs 13.18%, p = .02). All other 30-day outcomes were similar between the two groups.

CONCLUSION

COPD patients had 58.04% higher pulmonary complications while all other 30-day outcomes were comparable to their non-COPD counterparts. Therefore, close monitoring and timely intervention for pulmonary complications in COPD patients can be important after TEVAR for TBAD. Future studies should investigate long-term outcomes among these COPD patients.

Indications, safety, and effectiveness of transcatheter electrosurgical septotomy during endovascular repair of aortic dissections

OBJECTIVE

Endovascular repair of aortic dissections may be complicated by inadequate sealing zones, persistent false lumen perfusion, and limited space for catheter manipulation and target artery incorporation. The aim of this study was to describe the indications, technical success, and early outcomes of transcatheter electrosurgical septotomy (TES) during endovascular repair of aortic dissections.

METHODS

We reviewed the clinical data of consecutive patients treated by endovascular repair of aortic dissections with adjunctive TES in two centers between 2021 and 2023. End points were technical success, defined by successful septotomy without dislodgment of the lamella or target artery occlusion, and 30-day rates of major adverse events (MAEs).

RESULTS

Among 197 patients treated by endovascular repair for aortic dissections, 36 patients (18%) (median age, 61.5 years (interquartile range, 55.0-72.5 years; 83% male) underwent adjunctive TES for acute (n = 3 [8%]), subacute (n = 1 [3%]), or chronic postdissection aneurysms (n = 32 [89%]). Indications for TES were severe true lumen (TL) compression (≤16 mm) in 28 patients (78%), target vessel origin from false lumen in 19 (53%), creation of suitable landing zone in 12 (33%), and organ/limb malperfusion in four (11%). Endovascular repair included fenestrated-branched endovascular aortic repair (EVAR) in 18 patients (50%), thoracic EVAR/EVAR/PETTICOAT in 11 (31%), and arch branch repair in 7 (19%). All patients had dissections extending through zones 5 to 7, and 28 patients (78%) underwent TES across the renal-mesenteric segment. Technical success of TES was 92% (33/36) for all patients and 97% (32/33) among those with subacute or chronic postdissection aneurysms. There were three technical failures, including two patients with acute dissections with inadvertent superior mesenteric artery dissection in one patient and distal dislodgement of the dissection lamella in two patients. There were no arterial disruptions. The mean postseptotomy aortic lumen increased from 13.2 ± 4.8 mm to 28.4 ± 6.8 mm (P < .001). All 18 patients treated by fenestrated-branched EVAR had successful incorporation of 78 target arteries. There was one early death (3%) from stroke, and three patients (8%) had major adverse events. After a median follow-up of 8 months (interquartile range, 4.5-13.5 months), 13 patients (36%) had secondary interventions, and two (6%) died from non-aortic-related events. There were no other complications associated with TES.

CONCLUSIONS

TES is an adjunctive technique that may optimize sealing zones and luminal aortic diameter during endovascular repair of subacute and chronic postdissection. Although no arterial disruptions or target vessel loss occurred, patients with acute dissections are prone to technical failures related to dislodgement of the lamella.

Variability in the Treatment of High-Risk Type B Aortic Dissection at a Single Center

Although there are established high-risk features in acute type B aortic dissection (TBAD), its management is variable. This study characterizes complicated, uncomplicated, and high-risk TBAD in addition to their management and outcomes to gain insight into the actual significance of these high-risk features and the reality of real-world practice in managing TBAD. A retrospective review of 62 patients was conducted. Patient demographics, management, and outcomes were characterized and evaluated with Pearson's χ2 test, Fisher's exact test, or analysis of variance. Of the 32 high-risk TBADs, 66% (n = 21) received endovascular repair, 31% (n = 10) were medically managed, and 3% (n = 1) received hybrid (open and endovascular) repair. Refractory hypertension and pain (52%, n = 11) were the most common high-risk features in patients with high-risk TBAD who received endovascular repair. A maximum aortic diameter of >40 mm (67%, n = 6) was the most common high-risk feature in patients who received medical management. The most prevalent high-risk feature for all treatment groups in the high-risk TBADs was an aortic diameter of >40 mm (n = 16; 50%). Adverse postoperative outcomes were highest in the high-risk and complicated groups with endoleak as the most common adverse outcome (high-risk 12.9%, complicated 13.6%). Of the 62 patients, 47% (n = 26) had follow-up since their admission with an average follow-up time of 69 ± 166 days. The significance of high-risk features in the management of high-risk TBAD remains unclear. This single-center experience with managing acute TBAD reveals the reality of inadequate follow-up that may be specific to this disease process. This highlights a need to direct more efforts to assess long-term outcomes after treatment.

Emerging Trends in the Care of Type B Aortic Dissections

Aortic dissection is the most common of the acute aortic syndromes. Acute aortic dissection remains a highly morbid and potentially lethal condition despite contemporary advances in medical and surgical care. Type B aortic dissection (TBAD) is classified as uncomplicated, uncomplicated with high-risk features, and complicated. The role of thoracic endovascular aortic repair (TEVAR) in uncomplicated TBAD remains uncertain and is the topic of ongoing clinical trials. In most complicated cases, TEVAR is effective at restoring visceral and extremity blood flow. TEVAR has also been shown to arrest hemorrhage in the setting of thoracic aortic rupture. TEVAR has been demonstrated to induce satisfactory remodeling in the covered segment of the thoracic aorta, but progressive enlargement of the visceral aorta has led to a variety of techniques designed to promote remodeling in the uncovered aortic segment. There is a need to better define high-risk features so that treatment can be tailored to specific clinical conditions.

Physician-modified funnel-shaped covered stent for selective false lumen exclusion in chronic type B aortic dissection

PURPOSE

To describe the technique of off-centering a balloon-expandable covered stent for selective occlusion of a distal entry tear (ET) in a patient, conservatively treated for chronic type B aortic dissection (cTBAD), presenting FL expansion.

TECHNIQUE

A 63-year-old male, with conservatively managed cTBAD, presented at follow-up with FL partial thrombosis and expansion (thoracic aorta FL from 21 mm to 27 mm and abdominal aorta FL from 11 mm to 15 mm in 6 months). No proximal ET was identifiable. Distal FL perfusion was caused by an ET in the abdominal aorta feeding a 2 mm accessory renal artery (ARA). As the aortic diameter was below the threshold for endovascular repair, a selective occlusion of the distal ET and ARA was planned. A balloon-expandable covered stent was modified by off-centering the covered stent proximally and resulting in a funnel-shape occluder after deployment across the ET into the ARA. To prevent type Ic endoleak due to possible FL expansion caused by an intra-operatively detected phrenic artery (PA), coils were deployed into the lumen of the modified stent and the ARA. The pre-discharge computed tomography angiography showed exclusion of both the ARA and ET and a type 2 endoleak from the PA.

CONCLUSION

A balloon-expandable covered stent can be modified by off-centering the covered stent resulting in a funnel shape to adapt to different diameter requirements.

Extended aortic coverage in thoracic aortic endovascular repair is not associated with spinal cord ischemia

Objective

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains a debilitating complication, occurring in 10% of patients. Studies have shown that extended aortic coverage is a risk factor for SCI. This study evaluates whether extended aortic length coverage is a significant risk factor for SCI.

Methods

This study retrospectively reviewed 277 consecutive patients who underwent TEVAR successfully between 2006 and 2021 at a single institution. The patients were classified into 2 groups: ≥205 mm and <205 mm of thoracic aortic coverage. Analysis of variance was used to compare these variables and associated aortic coverage between the 2 groups. Univariable logistical regression was used to compare SCI and associated factors.

Results

Of the 269 patients who underwent successful TEVAR, 127 (47.2%) had ≥205 mm and 142 (52.8%) had <205 mm of aorta coverage. Patients with ≥205 mm of thoracic aorta coverage were more likely to be smokers (P < .01) and to have a history of previous stroke (P < .05). Patients with extended coverage were more likely to receive a preoperative lumbar drain (LD) (P < .01). Extended aortic coverage was not associated with a higher risk of SCI compared to standard aortic coverage (4.7% vs 4.2%; P = .84). Extended aortic coverage with or without a preoperative LD did not have an association with SCI (P = .91). Type II endoleaks were seen more in extended aortic coverage (P < .01).

Conclusions

Extended aortic coverage (compared with the standard approach) was not associated with a higher risk of SCI; however, this may have been mitigated by a higher prevalence of prophylactic lumbar drainage in this population.

Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis

PURPOSE

The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period.

MATERIALS AND METHODS

Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints.

RESULTS

In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was -5 mm (interquartile range [IQR]=-28 to 8 mm), -11 mm (IQR=-53 to 10 mm), and 7 mm (IQR=-13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen.

CONCLUSIONS

Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling.

CLINICAL IMPACT

In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.

The Impact of Oversizing in Thoracic Endovascular Aortic Repair on Long-Term Outcomes in Uncomplicated Type B Aortic Dissection: A Single-Center Retrospective Study

PURPOSE

The purpose of this study was to assess the impact of oversizing in thoracic endovascular aortic repair (TEVAR) on early and long-term survival and major adverse events in patients with uncomplicated type B aortic dissection (TBAD).

METHODS

Between January 2010 and December 2018, 226 patients who were diagnosed with uncomplicated TBAD and received TEVAR were analyzed retrospectively. The patients were divided into ≤5% oversizing (n=153) and >5% oversizing (n=73) groups. Primary end points were all-cause and aortic-related mortalities. Secondary end points were procedure-related complications, including retrograde type A aortic dissection (RTAD), endoleak, distal stent-induced new entry (SINE), and late reintervention. All-cause and aortic-related mortalities were assessed using the Kaplan-Meier survival method, while procedure-related complications were evaluated using a competing risk model with all-cause death as a competing risk.

RESULTS

Mean oversizing was 2.1%±1.5% in the ≤5% oversizing group and 9.6%±4.1% in the >5% oversizing group. Differences in the 30-day mortality and adverse events between the 2 groups were statistically insignificant. The freedom from all-cause mortality was comparable between the ≤5% oversizing group and the >5% oversizing group (≤5%: 93.3% at 5 years, >5%: 92.3% at 5 years, p=0.957). No significant difference was observed between both groups in the freedom from aortic-related mortality (≤5%: 95.0% at 5 years, >5%: 96.7% at 5 years, p=0.928). However, the competing risk analyses revealed that the cumulative incidence of RTAD was statistically significantly greater in the >5% oversizing group than in the ≤5% oversizing group (≤5%: 1(0.7%) at 5 years, >5%: 6(6.9%) at 5 years, p=0.007). All RTADs occurred within a year of TEVAR. The differences in the cumulative incidences of type I endoleak, distal SINE, and late reintervention were not significant between the 2 groups.

CONCLUSION

The differences in the 5-year all-cause mortality and aortic-related mortality between patients with uncomplicated TBAD who received TEVAR with ≤5% oversizing and those who got TEVAR with >5% oversizing were insignificant. However, oversizing >5% was considerably associated with an increased risk of RTAD within a year of TEVAR, suggesting that oversizing ≤5% may be the appropriate size for TEVAR in patients with uncomplicated TBAD.

CLINICAL IMPACT

For patients with uncomplicated TBAD, choosing oversizing ≤5% in endovascular treatment is beneficial to reduce the risk of postoperative retrograde type A aortic dissection. This finding provides a basis for stent size selection in endovascular repair. In addition, one year after TEVAR is the main time period for postoperative retrograde type A aortic dissection, and attention should be paid to the management and follow-up of this period.

Thoracic endovascular aortic repair for hyperacute, acute, subacute and chronic type B aortic dissection: Meta-analysis of reconstructed time-to-event data

Since the optimal timing for thoracic endovascular aortic repair (TEVAR) in the context of type B aortic dissections (TBAD) remains an open question, we performed a systematic review with meta-analysis to evaluate outcomes of TEVAR according to the phases of TBAD - hyperacute, acute, subacute and chronic. We carried out a pooled meta-analysis of time-to-event data extracted from studies published by June 2023 for the following outcomes: all-cause mortality, aortic-related mortality, and late aortic reinterventions. Thirteen studies met our eligibility criteria, comprising 4,793 patients (10.3 % hyperacute, 51.9 % acute, 25.9 % subacute, 11.9 % chronic). Considering the overall population, we observed a statistically significant difference between the groups (Log-rank test, P < 0.0001) and the main differences were found in the following comparisons: hyperacute versus acute (HR 1.61; 95 %CI 1.21-2.13; P = 0.001); hyperacute versus chronic (HR 1.70; 95 %CI 1.17-2.46; P = 0.005); subacute versus acute (HR 0.78; 95 %CI 0.63-0.98; P = 0.032). Considering the population with uncomplicated TBAD, we also observed a statistically significant difference for all-cause death between the groups (Log-rank test, P < 0.0001) and the main differences were found in the comparisons for subacute versus acute (HR 0.72; 95 %CI 0.58-0.88; P = 0.002). Furthermore, we observed statistically significant differences between the groups for aortic-related death (Log-rank test, P < 0.0001) and late aortic reintervention (Log-rank test, P < 0.0001), all favoring mostly the subacute phase as the optimal timing for TEVAR. In conclusion, there seems to be a timing-specific difference in the outcomes of TEVAR for TBAD pointing to the subacute phase as the optimal timing to achieve better long-term outcomes.

[Early Thoracic Endografting is Safe in Patients with Uncomplicated Type B Aortic Dissection]

There are many publications dealing with treatment options for uncomplicated type B aortic dissection (TBAD). Early TEVAR (Thoracic Endovascular Aortic Repair) may improve aortic-specific survival and delay disease progression in the long-term. Especially in patients with uncomplicated TBAD and additional high-risk features, preemptive TEVAR may improve late outcomes.We conducted a retrospective analysis of all patients treated for TBAD in our hospital between February 2017 and September 2021. Comorbidities, intraoperative data, 30-day mortality and postprocedural complications were analysed.During the above-mentioned period, 61 patients (38 males, median age 63 years) with TBAD were treated. Six patients received best medical treatment (BMT). 55 patients were treated by TEVAR and BMT. 11 patients (20%) had complicated TBAD, 12 patients (22%) had uncomplicated TBAD with high-risk features and 32 patients (58%) had uncomplicated TBAD. Technical success was 100%. No patient with uncomplicated TBAD died within the first 30 postoperative days. One patient with uncomplicated TBAD had a stroke after TEVAR. Two reinterventions were performed on day 7 and day 9 after TEVAR.Patients with uncomplicated TBAD could be treated by early TEVAR, with a low rate of perioperative complications. In patients with uncomplicated TEVAR and high-risk features, early TEVAR with BMT should be considered as the treatment of choice.

Mid- and long-term results of open repair for chronic type B aortic dissection in endovascular era

Medical management is the standard treatment of chronic type B aortic dissection (CTBAD). However, the roles of open surgical repair (OSR) and thoracic endovascular repair (TEVAR) in patients with CTBAD remain controversial. Thus, this study aimed to assess and compare the mid- and long-term clinical outcomes of OSR via left thoracotomy with that of TEVAR for CTBAD. The data of 85 consecutive patients who underwent surgery for CTBAD from April 2007 to May 2021 were retrospectively reviewed. The patients were divided into two groups: Group G, which included patients who underwent OSR, and Group E, which included patients who underwent TEVAR. Groups G and E comprised 33 and 52 patients, respectively. Preoperative and postoperative computed tomography (CT) studies were retrospectively analyzed for the maximum diameter. The mean duration of the follow-up period was 5.8 years. Operative mortality did not occur. There was no difference in complications, such as stroke (G: 2 vs. E: 0, p = 0.30), paraplegia (G: 1 vs. E: 1, p = 0.66), and respiratory failure (G: 2, vs. E: 0, p = 0.30). The difference in preoperative factors was observed, including the intervals between onset and operation (G; 4.9 years vs. E; 1.9 years, p < 0.01), maximum diameter in preoperative CT (G; 59.0 mm vs. E; 50.5 mm, p < 0.001), and maximum false lumen diameter (G; 35.5 mm vs. E; 29.0 mm, p < 0.01). There was no significant difference in the mid- and long-term survival rates (p = 0.49), aorta-related deaths (p = 0.33), and thoracic re-intervention rates (p = 0.34). Postoperative adverse events occurred in Group E: four cases of retrospective type A aortic dissection, two cases of aorto-bronchial fistula, and one case of aorto-esophagus fistula. Aorta-related death and re-intervention rates crossed over in both groups after seven years postoperatively. Although endovascular repair of CTBAD is less invasive, the rate of freedom from re-intervention was unsatisfactory. Some fatal complications were observed in the endovascular group, and the mid- and long-term outcomes were reversed compared with those in the OSR group. Although OSR is an invasive procedure, it could be performed safely without perioperative complications. OSR has more feasible mid- and long-term outcomes.

Predictors for thoracic aortic growth in patients with type B aortic dissection after thoracic endovascular aortic repair

OBJECTIVE

To identify independent predictors of thoracic aortic growth in patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

A retrospective analysis of the patients undergoing TEVAR for TBAD or intramural hematoma (IMH) from April 2014 to April 2023 was performed. The baseline morphological data of TBAD was established through computed tomography angiography (CTA) before discharge. Patients were divided into two groups based on aortic growth: growth and no growth. Aortic growth defined as an increase ≥5 mm in thoracic maximal aortic diameter during any serial follow-up CTA measurement. Logistic regression following propensity score matching (PSM) was used to identify independent predictors for aortic growth. Receiver operating characteristic curve and cutoff value of independent predictors were calculated. Linear regression was used to establish a correlation between anatomical variables and follow-up aortic diameter.

RESULTS

A total of 145 patients with TBAD (n = 122) or IMH (n = 23) undergoing TEVAR were included, with a male of 83.4% and a mean age of 56 ± 14.1 years. Patients in growth group and no growth group was 26 (17.9%) and 119 (80.1%), respectively. After using PSM method, matched regression analysis showed residual maximal tear diameter (OR = 0.889, 95% CI 0.830-0.952, p = 0.001) and follow-up aortic diameter (OR = 0.977, 95% CI 0.965-0.989, p < 0.001) were independent predictors for aortic growth. The cutoff value was 8.55 mm for residual tear diameter and 40.65 mm for follow-up maximal aortic diameter. The residual maximal tear diameter showed a linear correlation with follow-up aortic diameter (DW = 1.74, R2 = 6.2%, p = 0.033).

CONCLUSIONS

This study suggested that residual maximal tear diameter >8.55 mm and follow-up aortic diameter >40.65 mm could predict aortic growth in patients with TBAD undergoing TEVAR.

Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection

OBJECTIVE

Thoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD.

METHODS

This retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients' characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett's test. Survival and freedom from reintervention were estimated using Kaplan-Meier curves.

RESULTS

The follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years, and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3% ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 patients (86.8%) achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the eighth thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from reintervention was 84.7% and 84.7% at 1 and 3 years, respectively.

CONCLUSIONS

Intentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

Discussing on the Aortic Coverage in Type B Aortic Dissection Treatment: A Comprehensive Scoping Review

OBJECTIVE

The objective of this study is to investigate and address the question surrounding the determination of the optimal endograft length of coverage during TEVAR for type B aortic dissection (TBAD), with a particular emphasis on the distal landing zone (DLZ).

DATA SOURCES

MEDLINE, Scopus, and Web of Science databases were used.

METHODS

The PRISMA-ScR statement was followed.

RESULTS

Several variables can contribute to the length of coverage during TEVAR in TBAD patient. Baseline patient's characteristics, TBAD-related features, the type of endoprosthesis, and postoperative graft behaviour may contribute to the choice of coverage.

CONCLUSIONS

No robust data have been published regarding the optimal length of TEVAR. Therefore, reporting the percentage of covered aorta and improving computational studies should be valorised to improve postoperative outcomes.

The Evaluation of Outcomes after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection in Mainland China

BACKGROUND

To assess the mortality and outcomes after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD) in mainland China, and to compare these outcomes with data from Western countries, while analyzing the potential reasons for differences among different countries.

METHODS

An extensive literature search spanning from January 1999 to October 2023 was conducted using PubMed, Cochrane Library, and Embase databases for studies on endovascular treatment for TBAD. This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data extraction and analysis followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Primary outcomes were in-hospital mortality and mid-term (< 5 years) mortality.

RESULTS

Based on 25 publications (3,080 patients), pooled estimate for in-hospital mortality was 2.2% (95% confidence interval, 1.6%-2.9%). Major perioperative complications included stroke (2.4% [1.8%-3.3%]), spinal cord ischemia (1.4% [1.0%-2.2%]), retrograde type A aortic dissection (1.2% [0.8%-1.8%]), type I endoleak (5.6% [3.6%-8.6%]), visceral ischemia (1.0% [0.5%-2.1%]), and acute renal failure (2.8% [2.0%-3.8%]). Mid-term mortality was 5.1% (3.6%-7.3%), and secondary intervention rate was 4.9% (4.0%-6.0%) with 1.7% (1.0%-2.9%) conversion rate to open surgery. In subgroup analysis based on uncomplicated TBAD, in-hospital and mid-term mortality was 0.5% (0.2%-1.5%) and 0.6% (0.2-1.7%), respectively. Compared with data from Western countries, mainland Chinese patients had a lower mortality.

CONCLUSIONS

In mainland China, the outcomes of endovascular treatment for TBAD are comparable to those of Western countries. The large number of patients undergoing TEVAR in mainland China and its good performance support the use of TEVAR in uncomplicated TBAD.

Effect of False Lumen Occlusion Treatment With AFX VELATM, Candy-Plug Technique for Chronic Aortic Dissection

INTRODUCTION

We sought to examine midterm results and remodeling effect of false-lumen occlusion treatment using AFX VELA in case of chronic dissection repair.

MATERIAL AND METHODS

From June 2019 to May 2022, we performed false lumen occlusion treatment using a modified Candy-Plug technique with AFX VELA on 8 chronic aortic dissection patients with a patent false lumen. We collected operative data, short-term clinical outcomes, mid-term clinical outcomes and imaging test results. We conducted follow-up examinations at postoperative, 6-month and 1-, 2- and 3-year intervals, including contrast-enhanced computed tomography to evaluate the diameter, false lumen thrombosis and any events.

RESULTS

The average time from the symptom onset to the thoracic endovascular repair was 81.5 (35-155) months. The aorta showed aneurysmal dilation with an average maximum short-axis diameter of 58.9 (41-91) mm. Two cases needed emergency surgery due to rupture and impending rupture. There were no postoperative deaths. Complete thrombosis within the false lumen was achieved in 6 cases (75%), but 2 cases had incomplete thrombosis, requiring additional treatment. The mean maximum diameter showed a significant decrease at 6 months, 1 year and 2 years postoperatively compared to preoperative measurements (P < .05).

CONCLUSION

We showed the results of false lumen occlusion treatment using the AFX VELA cuff. We observed favorable clinical outcomes and remodeling effects. While the long-term durability and efficacy of this technique in aortic remodeling will need to be monitored with further observation, the use of this cuff is considered a reliable approach to false lumen occlusion treatment.

Acute Type B Aortic Dissection: Insights From a Single-Center Retrospective Experience Over 12 Years

INTRODUCTION

The treatment of acute type B aortic dissection (ATBAD) is currently a challenge for vascular surgeons, because of the early morbidity and mortality rates and the high risk of late aortic events up to 50% at 5 years. This study presents the initial outcomes of ATBAD treatment using optimal medical therapy alone or combined with proximal entry tear stent-graft coverage. Additionally, it provides an analysis of the evolution of the aortic diameter and its clinical consequences during the chronic phase in each group.

MATERIALS AND METHODS

Conducted as a retrospective, single-center study, we enrolled all consecutive ATBAD patients (n=130) treated between 2008 and 2020. The primary analysis studies the entire patient cohort based on their initial management approach, namely, medical treatment alone for uncomplicated ATBAD (n=67) or combined with stent-graft entry tear coverage (n=63). We also conducted a subgroup analysis to investigate factors associated with disease progression in the medical management group.

RESULTS

Median follow-up was 29.5 months. During this time aneurysmal evolution was observed in: 42.4% of cases in the medical group compared with 21.8% in the stent-graft group, primarily affecting the thoracic aorta. The stent-graft group exhibited significant aortic remodeling, with a decrease in false lumen (FL) and thoracic aortic diameters. Initial aortic diameter ≥40 mm and FL ≥22 mm were independent risk factors for aneurysmal degeneration. Five-year survival was consistent at 76.1% in both groups.

CONCLUSION

This study confirms the safety and efficacy of stent-graft entry tear coverage for ATBAD. Initial thoracic endovascular aortic repair (TEVAR) appears to reduce late aortic events by promoting aortic remodeling. Considering TEVAR's safety and potential to prevent late aortic complications, it may be considered for uncomplicated ATBAD patients with an initial aortic diameter ≥40 mm or an FL ≥22 mm.

CLINICAL IMPACT

This study validates the efficacy and safety of using endovascular stent grafts to seal the proximal entry tear in cases of acute type B aortic dissections, compared to optimal medical therapy. Aortic remodelling significantly benefits from endovascular stent graft coverage of the proximal entry tear. Given the heightened risk of late aortic events observed in the medical therapy cohort, there appears to be a necessity for including endovascular interventions in the management of uncomplicated acute type B aortic dissections, particularly when aortic diameter is ≥40 mm and false lumen diameter is ≥22 mm.

Transfer learning on physics-informed neural networks for tracking the hemodynamics in the evolving false lumen of dissected aorta

Aortic dissection is a life-threatening event that is responsible for significant morbidity and mortality in individuals ranging in age from children to older adults. A better understanding of the complex hemodynamic environment inside the aorta enables clinicians to assess patient-specific risk of complications and administer timely interventions. In this study, we propose to develop and validate a new computational framework, warm-start physics-informed neural networks (WS-PINNs), to address the limitations of the current approaches in analyzing the hemodynamics inside the false lumen (FL) of type B aortic dissection vessels reconstructed from apolipoprotein null mice infused with AngII, thereby significantly reducing the amount of required measurement data and eliminating the dependency of predictions on the accuracy and availability of the inflow/outflow boundary conditions. Specifically, we demonstrate that the WS-PINN models allow us to focus on assessing the 3D flow field inside FL without modeling the true lumen and various branched vessels. Furthermore, we investigate the impact of the spatial and temporal resolutions of MRI data on the prediction accuracy of the PINN model, which can guide the data acquisition to reduce time and financial costs. Finally, we consider the use of transfer learning to provide faster results when looking at similar but new geometries. Our results indicate that the proposed framework can enhance the capacity of hemodynamic analysis in vessels with aortic dissections, with the promise of eventually leading to improved prognostic ability and understanding of the development of aneurysms.

Navigating clinical appropriateness: A review of management strategies for type B aortic dissection

Aortic dissection is a catastrophic, life-threatening event. Its management depends on the anatomic location of the intimal tear (type A v B) and the clinical presentation in type B aortic dissection. In this article, the current evidence supporting clinical practice, gaps in knowledge, and the need for more rigorous research and higher-quality studies are reviewed.

Trends in the incidence, surgical management and outcomes of type B aortic dissections in Australia over the last decade

OBJECTIVES

This study aims to investigate the incidence and in-hospital outcomes of surgical repair for type B aortic dissection (TBAD) in Australia.

METHODS

Data were obtained from the Australasian Vascular Audit (AVA) and the Australian Institute of Health and Welfare (AIHW). The former is a total practice audit mandated for all members of the Australian and New Zealand Society for Vascular Surgery (ANZSVS) while the latter is an independent government agency which records all healthcare data in Australia. All cases of TBAD which underwent surgical intervention (endovascular or open repair) between 2010 and 2019 were identified using prospectively recorded data from the AVA (New Zealand data was excluded). The primary outcomes were temporal trends in procedures and hospital mortality; secondary outcomes were complications and risk factors for mortality. All admissions and procedures for, and hospital deaths from, TBAD in Australia were identified in AIHW datasets using the relevant diagnosis and procedure codes, with age-standardized rates calculated for the period 2000-01 to 2018-19.

RESULTS

A total of 567 cases of TBAD underwent vascular surgical intervention (AVA data, Australia). Of these, 96.3% were treated by endovascular repair. There was an increase in the annual procedure number from 45 in 2010 to 88 in 2019. In-hospital mortality was 4.8% for endovascular repair and 19% for open repair (p = 0.021). From 2000-01 to 2018-19, the age-standardized procedure rates for TBAD (Australia) doubled, the proportion of admitted patients undergoing a procedure rose from 28% to 43%, and in-hospital deaths fell by 25%.

CONCLUSION

There has been an increasing incidence of vascular surgical intervention for TBAD in Australia. The majority of patients received endovascular therapy while the mortality from surgically managed TBAD appears to be falling.

Novel insights into thoracic endografts technology for prevention of distal stent-graft induced new entry (dSINE) following endovascular repair of type B aortic dissections: from bench to bedside

INTRODUCTION

Endovascular treatment of type B aortic dissections (TBAD) has currently acquired a primary therapeutic role when anatomically feasible. The main issue with thoracic endovascular aortic repair (TEVAR) for aortic dissection is the actual nature of the aortic wall, which is structurally compromised and more fragile. Indeed, a wealth of data have shown that TEVAR for TBAD will lead, in a substantial proportion of cases, to a device-related adverse event named distal stent-graft induced new entry (dSINE).

AREAS COVERED

Currently available aortic stent-grafts have not been specifically devised for the treatment of aortic dissection. A novel dissection specific stent-graft (DSSG) was developed, which is a custom-made device based on the Zenith Alpha Thoracic platform (Cook Medical). The DSSG has several unique properties that, in principle, make its use optimal in TBAD patients.

EXPERT OPINION

TEVAR in the setting of aortic dissections remains technically challenging. The occurrence of dSINE represents a unique complication in this scenario and may lead to high rates of aortic-related adverse events and need for secondary interventions. The use of a novel custom-made DSSG in the setting of chronic TBAD has been proven to be safe, feasible and effective. However, even this approach may fail to completely prevent dSINE formation.

Preemptive treatment in the acute and early subacute phase of uncomplicated type B aortic dissections with poor prognosis factors

Objective

Due to its favorable outcome regarding late morbidity and mortality, thoracic endovascular repair (TEVAR) is becoming more popular for uncomplicated type B aortic dissection (TBAD). This study aimed to compare preemptive endovascular treatment and optimal medical treatment (OMT) and OMT alone in patients presenting uncomplicated TBAD with predictors of aortic progression.

Design

Retrospective multicenter study.

Methods

We analyzed patients with uncomplicated TBAD and risk factors of progression in two French academic centers. Aortic events [defined as aortic-related (re)intervention or aortic-related death after initial hospitalization], postoperative complications, non-aortic events, and radiologic aortic progression and remodeling were recorded and analyzed. Analysis was performed on an intention-to-treat basis.

Results

Between 2011 and 2021, preemptive endovascular procedures at the acute and early subacute phase (<30 days) were performed on 24 patients (group 1) and OMT alone on 26 patients (group 2). With a mean follow-up of 38.08 ± 24.53 months, aortic events occurred in 20.83% of patients from group 1 and 61.54% of patients from group 2 (p < .001). No patient presented aortic-related death during follow-up. There were no differences in postoperative events (p = 1.00) and non-aortic events (p = 1.00). OMT patients had significantly more aneurysmal progression of the thoracic aorta (p < .001) and maximal aortic diameter (p < .001). Aortic remodeling was found in 91.67% of patients in group 1 and 42.31% of patients in group 2 (p < .001). A subgroup analysis of patients in group 1 showed that patients treated with preemptive TEVAR and STABILISE had reduced maximum aortic diameters at the 1-year (p = .010) and last follow-up (p = .030) compared to those in patients treated with preemptive TEVAR alone.

Conclusion

Preemptive treatment of uncomplicated TBAD with risk factors of progression reduces the risk of long-term aortic events. Over 60% of medically treated patients will require intervention during follow-up, with no benefit in terms of postoperative events. Even after surgical treatment, patients in the OMT group had significantly more aneurysmal progression, along with poorer aortic remodeling.

Optimal Timing of Pre-emptive Thoracic Endovascular Aortic Repair in Uncomplicated Type B Aortic Dissection: A Network Meta-Analysis

BACKGROUND

This network meta-analysis compares outcomes of optimal medical therapy (OMT) and pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection at different phases of chronicity.

METHODS

MEDLINE and EMBASE were searched through November 2023. Pooled short-term outcomes (short-term mortality, perioperative complications) and long-term outcomes (all-cause mortality, aortic-related mortality, aortic re-intervention rates) were calculated.

RESULTS

Systematic review identified 17 studies (2 randomized controlled trials, 3 propensity score matching, and 2 inverse probability weighting). Subacute-phase intervention had lower short-term mortality than the acute-phase (hazard ratio [HR] [95% confidence interval [CI]]=0.60 [0.38-0.94], p=0.027). No significant differences were observed in aortic rupture and paraplegia. Acute-phase TEVAR had a higher stroke incidence than subacute-phase intervention (HR [95% CI]=2.63 [1.36-5.09], p=0.042), chronic (HR [95% CI]=2.5 [1.03-6.2], p=0.043), and OMT (HR [95% CI]=1.57 [1.12-2.18], p=0.008). Acute-phase TEVAR had higher long-term all-cause mortality than subacute-phase intervention (HR [95% CI]=1.34 [1.03-1.74], p=0.03). Optimal medical therapy had elevated long-term all-cause mortality compared with subacute-phase TEVAR (HR [95% CI]=1.67 [1.25-2.33], p<0.001) and increased long-term aortic-related mortality vs acute-phase (HR [95% CI]=2.08 [1.31-3.31], p=0.002) and subacute-phase (HR [95% CI]=2.6 [1.62-4.18], p<0.01) interventions. No significant differences were observed in aortic re-intervention rates.

CONCLUSIONS

Pre-emptive TEVAR may offer lower all-cause mortality and aortic-related mortality than OMT. Considering lower short-term mortality, perioperative stroke rate, and long-term mortality, our findings support pre-emptive TEVAR during the subacute phase.

CLINICAL IMPACT

The optimal timing of pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection remains uncertain. This network meta-analysis suggests that the subacute phase (14-90 days from symptom onset) emerges as the optimal timing for pre-emptive TEVAR. This window is associated with lower rates of short-term complications and higher long-term survival rates compared with alternative strategies.

Current perspectives in acute type B aortic dissections: a literature review

In this new millennial, endovascular strategies have revolutionized the treatment of acute type B aortic dissection (aTBAD). With reduced in-hospital mortality and good long-term outcomes TEVAR has become the gold standard for the treatment of complicated dissection and is gaining increasing support for its preventive applicability in some uncomplicated dissections. With this new paradigm came a shift of the treatment goal where just covering the entry tear is not enough and instead achieving long-term positive thoracoabdominal remodeling is needed. More extensive approaches with composite device designs (covered stent graft and bare metal stent) emerged to answer this aortic conundrum. At 5-year of follow-up, "Provisional ExTension To Induce COmplete Attachment technique" (PETTICOAT) and its evolution "Stent assisted balloon induced intimal disruption and relamination in aortic dissection repair" (STABILISE) seem to be safe techniques that can allow, when anatomically feasible, excellent aortic remodeling and, in some cases, even the healing of the dissection. Nevertheless, STABILISE results, although promising, are mostly based on small series and therefore need to be validated by analyzing medium-long-term results from the international registry. Given the plethora of new data and the disparity of expert opinions on the best treatment to adopt, in this review we aim to summarize the current knowledge on the results of these different strategies for acute TBAD.

Weekend Admission is Associated with Higher Kidney Failures after Thoracic Endovascular Aneurysm Repair for Stanford Type B Aortic Dissection

BACKGROUND

Weekend effect characterized by worse perioperative outcomes has been demonstrated in some surgery patients admitted on weekends, as opposed to weekdays. This study aimed to examine weekend effect on open surgical repair or thoracic endovascular aneurysm repair (TEVAR) for Stanford Type B Aortic Dissection (TBAD).

METHODS

Patients who underwent TBAD repair were identified in National/Nationwisde Inpatient Sample from Q4 2015-2020. Open surgery and TEVAR were examined separately. Multivariable analyses were performed comparing in-hospital perioperative outcomes of patients under weekday and weekend admission. Adjusted preoperative variables included sex, age, race, socioeconomic status, hospital characteristics, clinical symptoms, comorbidities, and elective/non-elective admission. Also, length of stay, days from admission to operation, and total hospital charge were compared.

RESULTS

Among patients who underwent open TBAD repair, 1321 were admitted on weekdays and 340 on weekends. Among patients who underwent TEVAR for TBAD, 2018 were admitted on weekdays and 440 wereadmitted on weekends. There was no difference in open repair outcomes between those admitted on weekdays vs weekends. In TEVAR, weekend admission was associated with higher post-procedural kidney failure (1.14% vs .20%, aOR = 4.11, P = .04) and superficial wound complications (2.73% vs 1.49%, aOR = 2.2, P = .03) but lower respiratory complications (5.80% vs 3.64%, aOR = .47, P = .01). Also, in TEVAR, weekend admission was associated with longer time from admission to operation (3.92 ± .27 vs 2.35 ± .09 days, P < .01).

CONCLUSIONS

Renal malperfusion was a common indication for TBAD repair. TBAD patients admitted over the weekend and underwent TEVAR had higher post-procedural kidney failure, which may be due to delayed diagnosis and treatment.

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

Diagnostic Ultrasound: On-Site Diagnosis of Type B Aortic Dissection During Cataract Surgery

We report a case of aortic dissection occurring during cataract surgery under local anesthesia, which was diagnosed on-site by point-of-care ultrasound. Intimal flaps were detected in the abdominal aorta, whereas the parasternal view showed no abnormalities in the aortic root or left ventricular function. According to these ultrasound findings, a Stanford type B aortic dissection was more likely than a type A aortic dissection, and imminent death was unlikely. Therefore, we decided to resume and complete the surgery. Subsequent computed tomography (CT) confirmed the point-of-care diagnosis. The patient was transferred to a tertiary hospital for medical treatment.

Treatment of Uncomplicated Type B Aortic Dissection: Optimal Medical Therapy vs TEVAR + Optimal Medical Therapy

Optimal Medical Therapy (OMT) has been the accepted mode of treatment for uncomplicated Type B Aortic Dissection (uTBAD). There is growing evidence that despite the short-term benefits of OMT, patients suffer deleterious consequences in the long-term with OMT alone. Thoracic Endovascular Aortic Repair (TEVAR) along with OMT has emerged as an alternative option for patients with uTBAD. This study evaluates the available literature for TEVAR + OMT as an alternative to OMT for treatment of uTBAD. In addition, issues related to TEVAR as a treatment for uTBAD are discussed.