Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with Marfan syndrome

Long-Term Longitudinal Computational Study of a Marfan Syndrome Patient After Hybrid Repair of Aortic Arch Dissection With Parallel Stent-Grafts

Hybrid repair is a valuable alternative treatment for aortic arch disease in Marfan syndrome patients after proximal aorta replacement. This study aimed to investigate the long-term durability of this technique with the use of parallel stent-grafts and evaluate strategies to prevent abdominal aortic dilation. One Marfan syndrome patient who underwent hybrid aortic repair with parallel stent-grafts for arch dissection after the Bentall procedure was admitted. Five patient-specific three-dimensional models were reconstructed based on preoperative and follow-up computed tomography angiography scans. Three hypothetical models addressing the closure of an endoleak or reentry tears were created. Hemodynamic parameters were assessed using computational fluid dynamics. Postoperatively, increased blood flow into the descending aorta and rising abdominal aortic pressure were observed. During the 5-year follow-up, no new thoracic aorta-related adverse events occurred. One early type III endoleak persisted, and three reentry tears were identified in the descending aorta. The abdominal aorta dilated from 31 to 49 mm. Simultaneously addressing both the endoleak and reentry tears was more effective in reducing false lumen pressure and flow velocity in the abdominal aorta and expanding the high-value relative residence time region. Longitudinal follow-up imaging demonstrated the long-term durability of hybrid aortic arch repair with parallel stent-grafts in a Marfan syndrome patient after ascending aorta replacement. The increased pressure resulting from blood flow redistribution was associated with downstream aortic dilation. Furthermore, computational fluid dynamics simulations can offer predictive analyses for optimizing intervention strategies in the treatment of distal aneurysmal degeneration.

Hybrid approach to achieve secure distal seal zones during endovascular aortic repair in a patient with Marfan syndrome

This report details a hybrid approach for treatment of abdominal aortic aneurysm in a patient with Marfan syndrome (MFS). A 34-year-old patient with MFS and prior open thoracoabdominal aortic aneurysm repair underwent bilateral common iliac artery interposition graft repair and endovascular aortic repair. The bifurcated stent graft was implanted into the previous thoracoabdominal graft proximally and iliac interposition grafts distally. Postoperatively, the patient recovered uneventfully with sac regression to 4.5 cm through 2-year follow-up, without seal zone degeneration. This hybrid approach aimed to eliminate landing zone degeneration in patients with MFS undergoing endovascular repair.

Diagnosis and treatment of cardiovascular disease in patients with heritable connective tissue disorders or heritable thoracic aortic diseases

Patients with heritable connective tissue disorders (HCTDs), represented by Marfan syndrome, can develop fatal aortic and/or arterial complications before age 50. Therefore, accurate diagnosis, appropriate medical treatment, and early prophylactic surgical treatment of aortic and arterial lesions are essential to improve prognosis. Patients with HCTDs generally present with specific physical features due to connective tissue abnormalities, while some patients with heritable thoracic aortic diseases (HTADs) have few distinctive physical characteristics. The development of genetic testing has made it possible to provide accurate diagnoses for patients with HCTDs/HTADs. This review provides an overview of the diagnosis and treatment of HCTDs/HTADs, including current evidence on cardiovascular interventions for this population.

Endovascular aortic repair in patients with Marfan and Loeys-Dietz syndrome is safe and durable when employed by a multi-disciplinary aortic team

OBJECTIVES

The aim of this study was to report on mid-term outcomes after endovascular aortic repair (EVAR) in patients with Marfan (MFS) or Loeys-Dietz (LDS) syndrome.

METHODS

We analysed data from 2 European centres of patients with MFS and LDS undergoing EVAR. Patients were analysed based on (i) timing of the procedure (planned versus emergency procedure) and (ii) the nature of the landing zone (safe versus non-safe). The primary end-point was freedom from reintervention. Secondary end-points were freedom from stroke, bleeding and death.

RESULTS

A population of 419 patients with MFS (n = 352) or LDS (n = 67) was analysed for the purpose of this study. Thirty-nine patients (9%) underwent EVAR. Indications for thoracic endovascular aortic repair or EVAR were aortic dissection in 13 (33%) patients, aortic aneurysm in 22 (57%) patients and others (intercostal patch aneurysm, penetrating atherosclerotic ulcer, pseudoaneurysm, kinking of frozen elephant trunk (FET)) in 4 (10%) patients. Thoracic endovascular repair was performed in 34 patients, and abdominal endovascular aortic repair was performed in 5 patients. Mean age at 1st thoracic endovascular aortic repair/EVAR was 48.5 ± 15.4 years. Mean follow-up after 1st thoracic endovascular aortic repair/EVAR was 5.9 ± 4.4 years. There was no statistically significant difference in the rate of reinterventions between patients with non-safe landing zone and the patients with safe proximal landing zone (P = 0.609). Furthermore, there was no increased probability for reintervention after planned endovascular intervention compared to emergency procedures (P = 0.916). Mean time to reintervention, either open surgical or endovascular, after planned endovascular intervention was in median 3.9 years (95% confidence interval 2.0-5.9 years) and 2.0 years (95% confidence interval -1.1 to 5.1 years) (P = 0.23) after emergency procedures.

CONCLUSIONS

EVAR in patients with MFS and LDS and a safe landing zone is feasible and safe. Endovascular treatment is a viable option when employed by a multi-disciplinary aortic team even if the landing zone is in native tissue.

Population risk profile analysis of acute uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair

BACKGROUND

Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR.

AIMS

The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes.

METHODS

A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE.

RESULTS

Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR.

CONCLUSION

Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.

Outcomes of thoracic aortic interventions in Marfan syndrome in the state of Texas over 11 years

OBJECTIVES

Marfan syndrome is a heritable connective tissue disorder with significant aortopathy and conveys substantial cardiovascular morbidity. This study characterizes the mortality and morbidities of thoracic aortic interventions (TAI) in the Marfan syndrome population in the state of Texas from 2009 to 2019.

METHODS

A retrospective review of the Texas Inpatient Discharge Dataset from 1 January 2009 to 31 December 2019. Discharges from acute care hospitals with a Marfan syndrome diagnosis by the International Classification of Diseases 9/10 codes and a procedure code for TAI were analysed utilizing descriptive, univariate and multivariable regression statistics.

RESULTS

There were 4641 Marfan syndrome discharges identified, of whom 644 (13.9%) underwent TAI. Thoracic or thoraco-abdominal aortic dissection or rupture was noted in 223 (34.6%). Thirty-three (5.1%) had a concomitant coronary artery intervention. There were 30 (4.7%) in-hospital mortalities, 126 (19.6%) diagnoses of acute renal failure (ARF), 52 (8.1%) had mechanical ventilation >96 h and the median length of stay was 10 [interquartile range (IQR) 7-16] days. After adjustment, concomitant coronary artery intervention was associated with in-hospital mortality [odds ratio (OR) 3.69 [IQR 1.15-11.90], P = 0.029] and ARF (OR 2.66 [IQR 1.19-5.94], P = 0.017). Aortic dissections/ruptures were associated with ARF (OR 1.73 [IQR 1.14-2.63], P = 0.010), ventilation >96 h (OR 2.19 [IQR 1.21-3.97], P = 0.010), and 15% longer length of stay (95% confidence interval 2.4-29.1%, P = 0.038).

CONCLUSIONS

TAI are frequent among the hospitalized Marfan Syndrome population. Concomitant coronary intervention is associated with increased risk of death and aortic dissections/ruptures are associated with increased morbidity. The high prevalence of aortic dissections/ruptures points to a potential target for improving imaging surveillance, adherence to treatment guidelines and preventative management of Marfan syndrome aortopathy.

Endovascular and Hybrid Repair in Patients with Heritable Thoracic Aortic Disease

OBJECTIVE

In individuals with heritable thoracic aortic disease (HTAD), endovascular repair for treatment of aortic aneurysm and dissection may be lifesaving but is associated with increased risk of failure of endovascular repair and adverse outcomes. This study reports our experience with early and late outcomes of endovascular aortic and branch vessel repair in patients with HTAD.

METHODS

A retrospective case series was performed by chart review of individuals with HTAD followed at Washington University School of Medicine/Barnes-Jewish Hospital who underwent endovascular aortic and/or branch vessel repair. Clinical features, imaging characteristics, and short- and long-term outcomes were collected.

RESULTS

Twenty-nine patients with HTAD (20 male; mean age 45 ± 13 years) underwent thirty-seven endovascular procedures between 2006 and 2020 with mean follow up of 54 ± 41 months. Seven patients underwent two or more separate endovascular procedures. Each procedure was considered separate for data collection and analysis. Underlying conditions included Marfan syndrome (n=16 procedures), Loeys-Dietz syndrome (n=14 procedures), vascular Ehlers-Danlos syndrome (n=3 procedures), and nonsyndromic HTAD (n=4 procedures). Twenty patients (69%) had prior open surgical aortic repair. Indications for endovascular aortic repair (n=31) included urgent repairs of acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and 8 chronic aneurysms). Six patients underwent elective endovascular repair of six branch vessel aneurysms or dissections. Six patients underwent hybrid open surgical and endovascular repair. Of the 37 procedures, twenty-five (68%) proximal landing zones were in the native aorta or branch vessel, eleven (30%) were in a surgical graft or elephant trunk and one was in a previously placed endograft. Thirty-six (97%) procedures were technically successful, and none required emergency surgical conversion. Two patients died: one from sepsis and one from presumed late pseudoaneurysm rupture, for a 5% per-procedure mortality rate. Two procedures were complicated by stroke and one patient developed paraparesis. Of the 31 aortic procedures, seven aortic endografts (23%) developed a stent-induced new entry (SINE) discovered with imaging at 20 ± 15 days post-procedure. Seven endografts (23%) developed a Type I endoleak and eight (26%) developed a Type II endoleak. No Type III endoleaks were seen. Within 30 days, two endografts (of 37, 5%) required reintervention. After 30 days, fifteen additional endografts (of 37, 41%) required reintervention. Two patients (of 6, 33%) who underwent hybrid repair required reintervention.

CONCLUSIONS

This study is the largest single-center case series examining outcomes of HTAD patients following endovascular repair. Urgent and elective endovascular repairs in patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection with relatively low risk. However, risk of early and late endoleaks and SINE is high. Close post-procedural surveillance is required, and many individuals will require additional interventions. Hybrid repair shows promise and requires further investigation.

Endovascular Repair in Patients with Marfan Syndrome: Concerns Amid Controversy

Endovascular aortic repair is widely used to treat patients with degenerative aneurysms or aortic dissection within the distal aorta. Thoracic endovascular aortic repair (TEVAR) is generally associated with fewer short-term complications than open surgical repair, which is particularly important for older patients with significant comorbid conditions. However, for patients with Marfan syndrome, a heritable thoracic aortic disease associated with aortic dilatation, dissection, and rupture, the utility of endovascular aortic repair remains questionable. Marfan patients have friable aortic tissue and are typically treated at a relatively young age; they therefore need a durable solution. Furthermore, those who need distal aortic repair tend to have chronic aortic dissection. Although TEVAR is generally superior to open surgery with regard to short-term complications, it is less durable, and TEVAR reintervention rates are highest in patients with chronic aortic dissection. Thus, Marfan patients seeking definitive aortic repair are often better served by open repair. Nonetheless, TEVAR may be useful in patients with Marfan syndrome as a bridge to open repair or as treatment for late complications of previous open repair.